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mtijcCitPofi^elugorfe 

OUcsc  of  l^tjpsiciansf  anb  ^urgcuns 


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?3r.  ebUiin  |!3.  Cragin 

1859-1918 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgicaldiseasesOOkeye 


THE   SURGICAL  DISEASES 


GENITO  -  URINARY    ORGANS 


INCLUDING    SYPHILIS 


BY 

K  L.  KEYES,  A.M.,  M.D. 


PKOFESSOR  OF  GENITO-URINARY  SURGERY,   SYPHILOLOGY,  AND  DERMATOLOGY,    IN  BELLE%a-E  HOS- 
PITAL MEDICAL  COLLEGE  ;    CONSULTING  SURGEON  TO  THE  CHARITY,  THE  BELLEVUE, 
AND  THE  SKIN  AND  CANCER  HOSPITALS  ;    CONSULTING  SURGEON  TO  THE 
BUREAU  OF  OUT-DOOR  RELIEF,   BELLEVUE  HOSPITAL  ; 
SURGEON  TO  ST.   ELIZABETH  HOSPITAL,  ETC. 


A  REVISION  OF  VAN  BUBEN  AND  REYES'S  TEXT-BOOK 
UPON  THE  SAME  SUBJECTS 


NEW    YOEK 

D.    APPLETON    AND    COMPANY 

1889 


Copyright,  1874,  1888, 
By  D.  APPLETON  AND  C03IPANY. 


PEEFAOE. 


Time  and  surgical  advance  have  destroyed  in  great  part  the 
valne  of  the  original  treatise  npon  v^hich  this  revision  is  founded, 
making  it  an  unsafe  guide  as  a  text-book  upon  certain  subjects. 
The  original  book  for  which  my  dear  old  master  and  myself  were 
mutually  responsible  was  issued  in  1874,  and  since  that  date  until 
the  present  time  has  received  no  material  alteration.  The  whole 
subject  of  litholapaxy  has  had  its  birth  snice  that  date;  supra- 
pubic cystotomy  has  been  restored  to  a  new  life ;  the  surgery  of  the 
kidney  has  been  constructed  anew,  and  radical  changes  have  been 
introduced  into  the  surgery  of  the  tunica  vaginalis  and  that  relating 
to  the  treatment  of  varicocele.  Many  minor  advances  have  been 
made  by  the  profession  all  along  the  line  followed  in  this  treatise. 

To  bring  the  book  up  to  date,  therefore,  it  became  necessary  to 
recast  it  entirely,  and  the  publishers  have  found  it  expedient  to 
destroy  the  old  stereotyped  plates  and  to  set  up  the  entire  book 
anew  in  type.  There  are  comparatively  few  pages  in  which  inter- 
polations of  more  or  less  importance  have  not  been  made. 

All  the  cases  have  been  left  out,  to  give  place  for  new  matter, 
and  several  of  the  chapters  (on  stone)  have  been  di'opped  entirely, 
being  replaced  by  others. 

In  this  way  it  has  been  possible  to  add  considerable  new  material 
without  materially  adding  to  the  number  of  pages.  The  plan  of 
the  original  book  has  been  scrupulously  adhered  to,  and  its  scope 
remains  unaltered. 

I  have  missed  the  kindly  counsel  and  the  matm-e  judgment  of 
my  friend  and  teacher,  without  which  the  original  of  this  work 
would  not  have  been  written.  His  absence  from  this  revision  is  to 
be  deplored;  but  I  feel  jiistifled  in  making  the  revision  because 
there  appears  to  be  a  demand  for  it,  and  because  all  the  text  of  the 


jy  PREFACE. 

original  work  came  from  my  pi'ii  except  Chaptei-s  XIV,  XV,  XVI, 
and  XVII  —  on  stone.  One  of  these  chapters  I  have  left  un- 
changed, out  of  respect  to  my  former  pai-tner ;  the  othei-s  have  been 
rewritten. 

The  book  as  it  stands  is  an  honest  exhibit  of  my  views  upon  all 
the  subjects  considered. 

E,  L.  Keyes. 

1  Park  Aveme.  New  Vokk.  Fehruanj,  ISSS. 


PREFACE  TO  THE  ORIGINAL  TREATISE. 


The  steady  growth  of  the  science  and  art  of  surgery  has  in- 
volved a  corresponding  increase  in  bulk  of  the  text-books  in  which 
its  principles  and  practice  are  set  forth — an  increase  already  sug- 
gestive of  either  a  limit  in  bulk  soon  to  be  reached,  or  the  omission 
or  slurring  over  of  special  subjects.  In  this  alternative  the  prepara- 
tion of  text-books  on  special  subjects  would  seem  to  be  the  appro- 
priate remedy. 

The  tendency  of  mankind  to  aggregate  in  large  and  constantly- 
increasing  cities  has  led  to  a  corresponding  tendency  to  the  growth 
of  specialists  in  the  different  departments  of  medicine  and  surgery ; 
and  the  development  in  large  cities  of  hospitals  and  schools,  and 
opportunities  for  teaching,  would  seem  to  render  them  the  natural 
repositories  of  accumulating  experience  and  the  sources  of  advanc- 
ing knowledge.  It  is  from  city  practice  and  hospital  experience, 
therefore,  that  the  materials  for  the  preparation  of  text-books  on 
special  subjects  would  be  naturally  sought,  and  from  these  sources 
the  substance  of  the  present  work  has  been  mainly  derived.  Its 
object  is  to  present  to  the  student  and  general  practitioner  a  suc- 
cinct account  of  the  nature  and  treatment  of  the  diseases  incident 
to  the  genito-urinary  organs  as  they  are  encountered  in  private  and 
hospital  practice  by  those  engaged  in  their  daily  and  especial  study. 
The  literature  of  this  department  of  surgery  has  been  carefully 
studied  with  the  purpose  of  reproducing  every  fact  of  practical 
value.  It  is  hoped  that  the  reader  will  recognize  a  conciseness  in 
the  grouping  of  these  facts  which  will  save  him  the  necessity  of 
reference  to  the  numerous  monographs  and  essays  from  which  they 
have  been  collected. 

On  account  of  the  general  character  of  the  work  as  a  text-book, 
it  has  been  impossible  to  refer  very  largely  to  personal  authority 
and  experience,  and  this  has  been  for  the  most  part  avoided  except 
in  reference  to  mooted  points  and  exceptional  or  noteworthy  phe- 
nomena. The  extent  of  the  subject-matter  treated  of,  and  the  ne- 
cessit}'  for  compression,  will  be  regarded,  it  is  hoped,  as  a  sufficient 


vi  PREFACE   TO   THE   ORIGIXAL   TREATISE. 

apology  for  terbcness  ami  directness  of  expression  or  defect  in  style, 
while  the  circumstance  of  joint-authorshij)  will  exjilain  any  lack  of 
uniforinity  in  manner  throughont  the  work,  of  which  the  prepara- 
tion for  the  press  has  devolvetl  mainly  upon  the  junior  author. 

The  plan  of  the  work  is  based  upon  an  anatomical  classiiication 
of  the  tissues  and  organs  of  which  the  diseases  and  deformities  form 
the  subjects  of  description.  This  necessitates  some  repetition  and 
frequent  reference  to  facts,  cases^  or  illustrations  already  given,  or 
to  be  given,  in  connection  witii  other  anatomical  divisions  of  the 
geuito  -  urinary  tract.  These  references  are  usually  made  thus: 
(Nephralgia),  (Plate  XX),  (Case  45),  the  page  not  being  specified, 
as  the  constant  appearance  of  signs  scattered  through  a  page  tends 
to  confuse  the  reader.  No  difficulty  need  be  experienced  in  turning 
to  these  references  promptly,  as  the  parenthetical  word,  case,  or 
plate  may  be  found  at  once  credited  to  its  proper  page  in  the  gen- 
eral index  at  the  end  of  the  book,  or  in  the  index  to  plates,  or  list 
of  cases,  at  its  commencement. 

The  terms  of  measurement  employed  are  uniformly  English, 
with  the  exception  of  the  centimetre  and  millimetre,  which  fre- 
quently occur  in  the  text.  These  may  be  readily  reduced  to  tlicir 
equivalent  in  inches  by  computation  from  the  subjoined  table.* 

The  subject  of  syphilis  is  included,  of  necessity,  in  a  treatise  like 
the  present.  Opportunities  for  the  observation  and  study  of  this 
disease  on  a  large  scale  fall  mainly  to  the  share  of  the  metropolitan 
hospital-surgeon  and  special  practitioner.  Although  properly  be- 
longing to  the  department  of  Principles  of  Surgery,  there  is  no 
disease  falling  within  the  limits  of  this  work  concerning  which  clear 
and  correct  ideas  as  to  nature  and  treatment  will,  at  the  present 
time,  so  seriously  influence  success  in  practice. 

Chapter  YIII,  Part  If,  on  "  Syphilitic  Diseases  of  the  Eye," 
has  been  kindly  furnished,  at  the  request  of  the  authors,  by  Prof. 
II.  D.  iSToyes,  M.  D.,  whose  authority  on  this  subject  is  undisputed. 

They  beg  leave  to  thank  Dr.  Eoosa  for  aid,  both  ju'rsonally  and 
through  his  excellent  work  "  On  Diseases  of  the  Ear,"  in  the  prep- 
aration of  Chapter  IX,  Part  II,  "  On  Syphilis  of  the  Ear." 

Aclcnowledgments  are  also  due  to  Dr.  Partridge  and  Dr.  Morri- 
son-Fiset,  of  the  house-staff  of  the  Charity  Hospital,  for  kind  assist- 
ance ;  and  to  Dr.  L.  A.  Stimsou  for  aid  in  many  ways. 

*  1  centimetre  =  4'433  lines,  or  "oO^YOS  inch ; 
1  millimetre  =    -443  line,    or -03937    inch; 
or,  roudilj,  1  millimetre  equals  half  a  line — about  one  twenty-fifth  of  an  inch. 

New  York,  June,  1S74. 


OOETTENTS, 


PART  I. 

DISEASES   OF  THE   GENITO-URINARY   ORGANS. 


CHAPTER  I. 

DISEASES   OF  THE  PENIS.  PAGE 

Anatomy.— Anomalies  ;  Double  Penis;  Absence  of  Penis.— Fracture,  Dislocation.— Cutaneous 
AfEections.— Tumors.— Cancer.— Amputation  of  Penis.— The  Prepuce  ;  Circumcision.— Phi- 
mosis ;  Remote  Results  of  Phimosis.— Paraphimosis.— The  Glans  Penis  ;  Herpes  Progeni- 
talis,  Balanitis,  and  Posthitis,  Vegetations,  Epithelioma.— The  Corpora  Cavernosa  ;  Inflam- 
mation, Ossification,  Calcification,  Gummy  Tumor,  Circumscribed  Chronic  Inflammation    .      1 

CHAPTER  II. 

DISEASES   OF  THE  URETHRA. 

Anatomy.— Natural  Curve  of  the  Urethra.— Proper  Curve  for  Instruments.- Catheterism  ;  Ob- 
stacles to  Catheterism  in  the  Healthy  Urethra.— Deformities  of  the  Urethra  ;  Imperforation, 
Atresia,  Hypospadias,  Hermaphrodism,  Epispadias.— Urethral  and  Sexual  Hygiene.— Injuries 
of  the  Urethra.— Urethral  Fever.- Foreign  Bodies.— Polypi 30 

CHAPTER  in. 

DISEASES   OF  THE  URETHRA. 

Inflammation.— Causes.— Subdivisions  :  Gonorrhoea  ;  Bastard  Gonorrhoea  ;  Urethritis.- Symp- 
toms.—Duration.— Course.— Gleet.— Complications  of  Urethral  Inflammation.— Treatment ; 
Method  of  performing  Injection  ;  Abortive  Treatment.— Methodic  Treatment  of  Increasing 
Stage,  including  Description  of  Wrappings  ;  of  Stationary  Stage,  including  Chordee  ;  of 
Decreasing  Stage,  including  Copaibal  Erythema.— Gleety  Stage  ;  Treatment  of  Gleet.— The 
Endoscope.— Rare  Sequelse  of  Gonorrhoea 54 

CHAPTER  IV. 

COMPLICATIONS  OF  GONOERHCEA. 

Folliculitis.— Inflammation  of  Lacuna  Magna.— Cowperitis.-Peri-urethritis.— Adenitis.— Lym- 
phitis.— Gonorrhoeal  Rheumatism  ;  Hydrarthrosis,  inflammatory  :  affecting  Sheaths  of  Ten- 
dons ;  Bursas.— Diagnostic  Table  of  Simple  and  Gonorrhoeal  Rheumatism.— Gonorrhoeal 
Ophthalmia.— Gonorrhosal  Conjunctivitis.— Diagnostic  Table  of  Gonorrhoeal  Conjunctivitis 
and  Gonorrhoeal  Ophthalmia 82 

CHAPTER  V. 

STRICTURE  OF  THE  URETHRA. 

Definition.— Varieties  ;  Muscular,  Organic— Organic  Stricture.— Form.— Xumber.— Seat.— Tlie 


Lesion  in  Stricture.- Causes.— Time  of  Occurrence  of  Stricture.— Irritable  and  Resilient 
Stricture 


98 


viii  CONTENTS. 


CHAPTER  VI. 

STRICTURE   OF  THE   I-RETIIRA.  PAOR 

Instnimcnts  and  (heir  I'sc— Filiform  Bougies  with  Mananivrcs  alone,  and  as  Guides.— Bougies. 
—Bulbous  Bougies.— Catheters.— Sounds.— Scale.— Advantages  of  Steel  Instruments.— In- 
struments for  Divulsion  with  Manoeuvres.— Instruments  for  Internal  Urethrotomy  with  3Ia- 
nanivres.— Perineal  Urethrotomy  with  and  without  a  Guide.- Rectal  Puncture.— Supra-pubic 
Puncture. — Uieulafoy's  Aspirator 109 

CHAPTER  Vn. 

STRICTURE  OP  THE  URETURA. 

Diagnosis.— Use  of  Bulbous  Bougie.— Symptoms  of  Stricture  and  its  Results  as  affecting  the 
Urethra,  Bladder,  Kidneys,  Testicles,  Rectum,  Nerves,  etc.,  including  a  Consideration  of  In- 
filtration, and  the  Harmlessness  of  Healthy  Urine  in  contact  with  the  Tissues.— Causes  of 
Death  from  Stricture. — Recapitulation  of  Symptoms  and  Effects  of  Stricture  ....  130 

CHAPTER  VIII. 

TRE.\TMEXT   OF   STRICTUKE   OF  TUE   URETHRA. 

With  Details  for  all  Complications,  and  a  Recapitulation 146 

CHAPTER  IX. 

DISEASES   OF  THE   PROSTATE. 

Anatomy.— Function.— Deformities.— Injuries. — .\trophy.— Hypertrophy.- Bar  at  the  Neck  of 
the  Bladder.— Symptoms  and  Results  of  Hypertrophy. — Course  of  Symptoms  from  commenc- 
ing Irritability  up  to  Retention,  Atony,  Stone,  Uraemia,  Death IC9 

CHAPTER  X. 

DISEASES   OF   THE   PROSTATE. 

Hypertrophy  (continued).— Diagnosis  ;  Description  of  Instruments  and  Manoeuvres  cmploj'cd  in 
their  Use.— Examination  of  Patient.— Methods  of  retaining  Catheters  in  the  Bladder. —Meth- 
ods of  deciding  upon  the  Character  and  E.\tent  of  Prostatic  Deformity  as  affecting  the 
Course  of  the  Urethra. — Treatment.— Treatment  of  Complications.— Interna!  Remedies  in 
Prostatic  Disease.— Natural  Mode  of  Death  due  to  Hypertrophied  Prostate  .       .       .184 

CHAPTER  XI. 

DISEASES   OF   TUE   PROSTATE. 

Congestion.— Parenchymatous  Prostatitis.— Terminations  :  in  Resolution,  Chronic  Prostatitis, 
Abscess.— Treatment.— Gonorrhoea!  Prostatitis.- Prostatic  and  Peri-prostatic  Abscess.— 
Treatment  of  all  Forms  of  Abscess.— Follicular  Prostatitis.- Its  Liability  to  be  mistaken  for 
Stone  in  the  Bladder. — Treatment. — Tubercular  Prostatitis. — Cancer  of  the  Prostate. — Pros- 
tatic Concretions.— Prostatic  Calculi.- Neuralgia  of  the  Prostatic  Urethra.— Syphilis  of  the 
Prostate 205 

CHAPTER  XII. 

DISEASES   OF  TUE   BLADDER. 

Anatomy. — Anomalies  and  Deformities,  Exstrophy. — Hernia  of  Bladdcr.—Hypertrophy.— Atro- 
phy.—Wounds.-Rupture  of  the  Bladder.— Foreign  Bodies.— Retention  of  Urine. -Inconti- 
nence :  in  Children,  in  Adults.— Tenesnius.-Chorea.-HKmaturia.-Neuralgia  of  the  Vesi^ 
cal  Neck.— Cause.- Symptoms.— Diagnosis.- Treatment 218 

CHAPTER  XIII. 

DISEASES   OF  THE   BLADDER. 

Acute  Cystitis.— Gonorrhoeal  Cystitis.— Diagnostic  Table  of  Cystitis  of  the  Neck  and  Prosta- 
titis.- Pathological  Lesions  in  Cystitis.— Treatment.— Chronic  Catarrh  of  the  Bladder.— 
Atony  of  the  Bladder.— Paralysis,  Heterologous  Deposits,  and  Tumors  in  the  Bladder- 
Walls    243 

CHAPTER  XIV. 

STONE  IN  THE   BLADDER. 

Materials  of  which  Calculi  are  formed.— Causes  of  Stone,  internal  and  external.— Number.— 
Size.— Shape.— Weight.— Degree  of  Hardness.— Possible  Consequences  of  Stone,  including 


CONTENTS.  jjj 

PAOE 

Symptoms,  Pathology,  and  Modes  of  Death.— Symptoms  considered  in  Relation  to  Dia^o- 
sis  and  Selection  of  Mode  of  Cure.— Sounding.— Circumstances  prejudicial  to  a  Choice  of 
Lithotrity 2C3 

CHAPTER  XV. 

TKBATMENT   OF  STONE   OTHEU  THAN   JtADICAL. 

The  Preventive  Treatment  of  Stone.— The  Electrolytic  Treatment  of  Stone.— The  Solvent 
Treatment  of  Stone,  General  and  Local.— The  Palliative  Treatment  of  Stone  ....  280 

CHAPTER  XVI. 

LITHOLAPAXY. 

Modem  Improved  Lithotrity.— Cases  suitable  for  this  Operation.— Instruments?  used,  and  their 
Method  of  Employment.— After-treatment.— Complications.— Litholapaxy  in  Women.- 
Relapse 290 

CHAPTER  XVII. 

LITHOTOMY. 

The  Lateral  Operation.- Cases  suitable  for  it.— Instruments  employed.— Operative  Method.— 
After-treatment.— The  Lateral  Operation  in  Children.— The  Median  Operation.— Cases  suit- 
able for  it.— Operative  Method.— Complications  of  Lithotomy.— Relapse  after  Lithotomy    .  297 

CHAPTER  XVin. 

SUPRA-PUBIC  LITHOTOMY. 

Cases  Suitable  for  the  Operation. — Operative  Method.— After-treatment 312 

CHAPTER  XIX. 

DISEASES   OF  THE  URETERS. 

Anatomy.— Anomalies.— Chronic  Inflammation.— Dilatation.— Stricture.— Wounds      .       .       .310 

CHAPTER  XX. 

DISEASES   OF  THE   KIDNEY. 

Anatomy.— Anomalies.— Floating  Kidney.— Nephrorraphy.— Injuries.— Suppression  of  Urine.— 
Nephralgia.— Phosphatic  Urine.— Oxaluria.— Gravel  and  Kidney-Stone.— Nephritic  Colic— 
Nephro-lithotomy.— Pyelitis,  Pyelonephritis,  and  Perinephritic  Abscess.— Pyelitis.  Patho- 
logical Lesions.— Causes.— Calculous  Pyelitis.— Perinephritic  Abscess,— Treatment  of  Pyeli- 
tis. —Hydronephrosis.— Kidney-Cysts.— Hydatids.— Tubercle.— Cancer.— Other  Tumors  of 
the  Kidney.— Nephrotomy.— Nephrectomy.— Syphilis  of  the  Kidney 317 

CHAPTER  XXI. 

DISEASES   OF  THE   SCROTUM. 

Anatomy.— Injuries.— (Edema.— Emphysema.— Eczema.— Intertrigo.— Pityriasis.— Eczema  Mar- 
ginatum.—Pruritus  Genitalium.— Pediculi  Pubis.— Phlegmonous  Erysipelas.— Elephantiasis. 
—Tumors  and  Cancer  of  Scrotum.— Epithelioma 3,53 

CHAPTER  XXn. 

DISEASES   OF   THE   TESTICLE. 

Anatomy.  —  Anomalies.  —  Cryptorchidism.  —  Luxation.  —  Hypertrophy.  —  Atrophy.  —  Injuries. 
— Hsema tocele.— Hematocele  of  the  Cord.— Free  Bodies  in  the  Tunica  Vaginalis    .        .        .362 

CHAPTER  XXin. 

DISEASES  OF  THE  TESTICLE. 

Hydrocele,  acute,  chronic— Diagnostic  Table  of  Chronic  Hydrocele  with  Incarcerated  Hernia.- 
Palliative  Treatment.— Radical  Treatment.— Congenital  Hydrocele.— Diagnostic  Table  of 
Congenital  Hydrocele  and  Hernial  Tumor.— True  and  Spurious  Hydrocele  of  Hernial  Sac- 
Encysted  Hj-drocele  of  Testis.— Spermatocele.-Spermatic  Congestion.— Origin  of  Sperma- 
tocele—Hydrocele of  Cord,  diffuse,  encysted 374 


X  CONTENTS. 

CHAPTER  XXIV. 

DISEASES   or  THE  TESTICLE.  PAOE 

Inflammation.—  Orchitis.—  C.iuscs.-  Symptoms.—  Pathologlciil  Changes.—  Prognosis.  —  Treat- 
ment.—Epididymiiis.-Frequency  and  Date  of  Appearance  in  Gouorrha'a.— Causes.— Symp- 
toms.—Sterility  as  a  Kesnit  of  Epididymitis.— Diagnostic  Table  of  Orchitis  and  Epididy- 
mitis.—Treatment  of  Epididymitis 388 

CHAPTER  XXV. 

DISEASES   OF  TUE   TESTICLE. 

Psendo-tubcrcnlar   Epididymitis.— Tubercular    Testis.— Symptoms.— Pathology.— Treatment 

Sypliilitic  Epididymitis.— Syphilitic  Orchitis  ;  Interstitial  ;  Gnmniy.— Cancer.— Sarcoma.— 
Diagnostic  Table  of  Syphilitic  Testis,  Tubercular  Testis,  Cancer,  Sarcoma,  including  Diag- 
nostic Features  of  Different  Fungi.— Castration.— Dermoid  Cyst.— Irritable  Testis.— Neu- 
ralgia Testis 406 

CHAPTER  XXVI. 

MALADIES  INVOLVING    TUE  GENITAL  FUKCTION. 

Impotence.— True  Impotence,  its  Causes  and  Treatment.— False  Impotence,  its  Causes  and 
Treatment. — Sterility.— Masturbation.— Pollution,  Nocturnal  and  Diurnal.  —  Spermatorrhoea. 
—Erotomania.— Satyriasis.-Priapism.— Aspermatism 427 

CHAPTER  XXVII. 

DISEASES   OF  THE  CORD. 

Anatomy.— Spasm  of  Cremaster. — Varicocele,  mild,  severe 449 

CHAPTER  XXVIII. 

DISEASES   OP  THE   VAS   DEFEUENS   AND   SEMINAL   VESICLES. 

Anatomy.— Inflammation,  acute  and  chronic 455 


PART  II. 

CHANCROID  AND   SYPHILIS. 


CHAPTER  I. 

CUANCROID. 

Definition.— Transmissibility  to  Animals.— Cause  of  Chancroid.- Indefinite  Inoculability.— Rela- 
tive Frequency.— Methods  of  Conta£;ion.— Explanation  of  Apparent  Long  Period  of  Incu- 
bation.— Situation  of  Chancroid.— Symi)toins.— Course.— Character  of  Scar.— Variation  of 
Chancroid  from  Tj-pe,  in  Initial  Form,  in  Shape,  in  Number,  in  Size,  in  Duration,  in  Pain, 
in  Condition  of  Base,  in  Course  (Relapse).— Complication  by  Vegetations,  by  Syphilitic 
Chancre,  by  Inflammation,  by  Gangrene  and  Gangrenous  Phagedena,  by  PuJtaceous  Pha- 
gedena, by  Bubo,  by  Lymphangitis.— Diagnosis  of  Chancroid.— Prognosis      ....  400 

CHAPTER  n. 

CHANCROID. 

Prophylactic  Treatment.— Local  Treatment  of  Chancroid.— Local  Treatment  of  Phagedena.— 
General  Treatment  of  Chancroid. —  Bubo  ;  simple;  virulent. —  Treatment  of  Bubo. — 
Lymphangitis  ;  simi)le  ;  virulent  ;  syphilitic. — Treatment  of  Lymphangitis    ....  479 

CHAPTER  III. 
sypuiLis. 
Nature.- Unity  and  Duality.  —  Length  of  Time  required  for  Absorption  of  Virus.- Analogy 
with  Vaccine  Virus.  —  Second  Attacks  of  True  Syphilis.  —  Transmissibility  to  Animals.- 


CONTENTS. 


XI 


PACK 

Incubation  of  Syphilitic  Chancre.— Induration,  parchment-like,  split-jx^a,  diffuse— Ulcer- 
ation.—Secretion.— Pain. — Nature  of  Scar.— Auto- and  Iletero-rnoculution.— Vaccinal  Syph- 
ilis.—Multiple  Inoculation.  — Fluids  capable  of  transmitting  SypliiliH  by  Inoculation.— 
Methods  of  Transmission  of  Syphilis. — Duration  of  Chancre.— Number.— Size.— Situation. — 
Form.— Symptoms  of  Urethral  Chancre. —  Course  of  Chancre. —Complications. —  "Mixed 
Chancre."  — Transformation  mto  Mucous  Patch.  —  Phagedena  and  Gangrene.  —  Treat- 
ment of  Chancre.— Syphilitic  Bubo.— Lymphangitis      402 

CHAPTER  IV. 

SYPHILIS. 

Diagnostic  Table  of  Syphilitic  Chancre,  Chancroid,  Herpes,  and  Ulcerated  Abrasion.— Of  Syphi- 
litic Bubo  and  the  Bubo  of  Chancroid.— Of  Svphilitic  Lymphangitis,  and  the  Lymphangitis 
of  Chancroid.— General  Syphilis.— Secondary,  Tertiary,  Malignant,  Irregular,  and  Inter- 
mediary Syphilides.  —Prognosis  of  Syphilis.  —  Duration.  —Influence  of  Gout  and  Scrofula 
upon  the  Course  of  Syphilis.— The  Ten  General  Characteristics  of  Syphilides.— Concomitant 
Symptoms  of  Secondary  Syphilis.  —  Secondary  Incubation,  Syphilitic  Fever,  Alopecia, 
Indolent  Glandular  Engorgement,  Sore  Throat,  Analgesia 526 

CHAPTER  V. 

GENERAL  TREATMENT  OF  SYPHILIS. 

Hygienic,  Tonic,  Specific  Treatment.  —  Syphilization.  —  Treatment  of  Early  Syphilis. —Bad 
Effects  of  Mercury.— Methods  of  administering  Mercury.— Treatment  of  Late  Syphilis.— 
Mixed  Treatment.— Treatment  by  the  Iodides.— Methods  of  administering  Iodine  in  Syphi- 
lis.—Quantity  of  Iodide  which  may  be  required.— Duration  of  General  Treatment .        .        .  5.50 

CHAPTER  VI. 

SITIIILIS   OF   SKIN  AND  MUCOUS   MEMBRANES, 

Syphilides,  Secondary  and  Tertiary.— The  Secondary  Syphilides.— Concomitant  Symptoms  on 
Mucous  Membranes 5S3 

CHAPTER  VII. 

SYPHILIS  OF   SKIN  AND  MUCOUS   MEMBRANES. 

The  Tertiary  Syphilides.— Concomitant  Symptoms  on  Mucoits  Membranes COO 

CHAPTER  Vin. 

SYPHILIS  OF   THE  EYE- 

The  Lachrymal  Apparatus. — The  Eyelids  :  Chancre,  Mucous  Patches,  Gummy  Tumors,  Ptosis. — 
The  Conjunctiva.— The  Sclera.— The  Cornea.— The  Iris  ;  Mydriasis  ;  Iritis,  Varieties  and 
Complications,  acquired  and  hereditary. — Prognosis. — Treatment. — Vitreous  Humor,  Hya- 
litis. — Crystalline  Lens,  Cataract. — Cyclitis. — Choroiditis,  exudative  and  atrophic. — ^Retini- 
tis.— Neuritis  Optica. — Paralysis  of  Muscles.— Periostitis 609 

CHAPTER  IX. 

SYPHILIS   OF  THE  EAR. 

Syphilis  as  affecting  the  External,  Middle,  and  Internal  Ear 631 

CHAPTER  X. 

STPHILIS   OF   SPECIAL  TISSUES   AND  ORGANS. 

Syphilis  of  the  Nails.— Dactylitis.— Syphilis  of  Tendons,  Sheaths  of  Tendons,  and  Aponeuro- 
ses.—Syphilis  of  Muscle.— Syphilis  of  Joints.— Sj-philis  of  Bone.— Syphilis  of  Cartilage — 
Syphilis  of  Lymphatic  Glands.— Syphilis  of  the  Mammary  Gland 633 

CHAPTER  XI. 

VISCERAL   STPHILIS. 

Syphilis  of  the  Vascular  System.- Syphilis  of  the  Respiratory  System.— Syphilis  of  the  Di- 
gestive System,  including  the  Tongue  and  the  Great  Abdominal  Glands.— Syphilis  of  the 
Peritonaeum,  Thyroid,  and  Tliymus.— Syphilis  of  the  Geuito-Urinary  System  .        .        .        .647 


xii  CONTENTS. 

CHAPTER  XII. 
STrnrLi9  of  the  nervous  system.                                         paqb 
The  Lesions :  Symptoms,  Prognosis,  Treatment.— Genoral  Cliaraeteristics  of  Nervous  Symp- 
toms in  nil  Cases.— Syphilis  of  x\u-   Hrain.— Syphilis' of  the  Cord.— Syphilis  of  Special 
Nerves  .        .   " COS 

CHAPTER  XIII. 

INHEUITED   SYPHILIS. 

Inheritance  from  either  Parent,  the  other  remaining  sound.— Abortion  due  to  Syphilis.— Date  of 
Appearance  of  Symptoms.— Symptoms.— Visceral  Syphilis.— The  Syphilitic  Countenance- 
Treatment  of  Inherited  Syphilis C79 


LIST  OF  ILLUSTEATIOI^S. 


FIGUnE  PAGE 

1.  Transverse  section  of  penis  (flaccid) 2 

2.  Transverse  section  of  penis  (erect) 2 

3.  Forceps  for  circumcision 12 

4.  Method  of  reducing  paraphimosis 18 

5.  Method  of  reducing  paraphimosis 19 

6.  Method  of  reducing  paraphimosis 19 

7.  Diagram  of  the  urethra 31 

8.  Lacuna  magna 32 

9.  Vertical  section  through  glans  and  fossa  navicularis 32 

10.  Transverse  section  of  spongy  urethra 32 

1 1.  Transverse  section  of  prostatic  urethra 32 

12.  Proper  curve  for  conical  urethral  instruments  {o,  b) 34 

13.  Faulty  curve  («,  6) 34 

14.  Proper  curve 34 

15.  Passing  the  sound,  first  position 35 

16.  Passing  the  sound,  second  position 36 

17.  Passing  the  sound,  third  position 36 

18.  Passing  the  sound,  fourth  position 37 

19.  Conical-pointed,  hard-rubber  syringe 65 

20.  Conical-pointed  glass  tip  for  syringe 66 

21.  Keif'er's  hard-rubber  syringe  nozzle 67 

22.  Soft-rubber  universal  injector 67 

23.  Rubber-capped  glass  pipette 69 

24.  Syringe  for  deep  urethral  injections 78 

25.  Linear  stricture  of  the  urethra 102 

26.  Annular  stricture  of  the  urethra 102 

27.  Soft  catheter  for  introduction  on  two-foot  guide 110 

28.  Soft  catheter,  with  screw-tipped  guide 110 

29.  Tips  of  whalebone  guides 110 

30.  Banks's  whalebone  bougies Ill 

31.  False  passages  in  the  urethra Ill 

32.  Olivary  bougies,  properly  made  {A) 112 

32.  Olivary  bougies,  improperly  made  {B) 112 

33.  Head  of  bulbous  bougie 113 

34.  Otis's  urethrometer 113 

35.  Silver  catheter - 114 

36.  Bumstead's  catheter,  with  whalebone  guide 114 

37.  Conicity  of  steel  sounds 115 

38.  Conical  tunneled  sound = ,  115 

39.  American  and  French  scales 116 

40.  Thompson's  rapid  dilator 118 


xiv  LIST   OF   ILLUSTRATIONS. 

FIGUUE  PAGE 

41.  Civialo's  uretlivotonie 120 

42.  lliiisonncuve's  uictbrotonu',  Buinstiad's  modification 121 

43.  Maisonneuve's  urethrotome,  Voillemior's  moditicatiou 121 

44.  Otis's  dilating  urethrotome 122 

45.  Blunt  grooved  staff  for  perineal  section 123 

46.  Blunt  grooved  staff  for  perineal  section,  with  guide 1 28 

47.  Goulcy's  cathcter-staif 123 

48.  Dieulafoy's  small  aspirator 127 

4y.  Soft-rubber  tube  to  be  worn  in  suprapubic  puncture 129 

50.  Silver  tube  to  be  worn  in  suprapubic  puncture 131 

51.  Pocket  at  inferior  commissure  of  the  meatus 132 

52.  Dilatation  of  urethra  behind  stricture 133 

53.  False  passage 155 

54.  Hvpertrophy  of  the  prostate,  with  false  passage ' 173 

55.  Hypertrophy  of  upper  portion  of  prostate 174 

56.  Posterior  median  hypertrophy 176 

57.  Posterior  median  hypertrophy 177 

58.  Healthy  prostate 177 

69.  Sacculated  bladder 179 

60.  Long-curved  silver  catheters 185 

61.  Thompson's  curve  for  soft  catheter 187 

62.  Mcrcier's  catheter  coudec  (A) 188 

82.  Mercier's  catheter  bi-eoudee  (B) 188 

63.  Soft-rubber  catheter 188 

64.  Otis's  stylet 189 

65.  Keyes's  stylet 189 

66.  Squire's  vertebrated  catheter 190 

67.  Gross's  spiral  catheter.. 190 

68.  Mercier's  false-passage  catheter 190 

69.  Thompson's  stone-searcher 191 

70.  Posterior  median  prostatic  hypertrophy 192 

71.  Harrison's  bulbous  bougies 193 

72.  Rubber  bag  for  vesical  injection 197 

73.  Fountain  syringe,  with  two-way  stop-cock 197 

74.  Rubber  urinal 199 

75.  Urinal  for  exstrophy  of  the  bladder 224 

76.  Thompson's  searcher 277 

77.  Mercier's  sonde  coudce 277 

78.  Bigelow's  lithotrite 291 

79.  Jaws  of  Bigelow's  lithotrite  (open) 291 

80.  Jaws  of  Bigelow's  lithotrite  (closed) 291 

81.  Wheel  of  Bigelow's  lithotrite 292 

82.  ReHquet  pattern  of  lithotrite  jaws 292 

83.  Bigelow's  wash-bottle 293 

84.  Keyes's  straight  tube  for  washing  bladder 29 1 

85.  Keyes's  curved  tube  for  washing  bladder 294 

86.  Staff  for  lateral  lithotomy 299 

87.  Scalpel  for  lithotomy 299 

88.  Blizard's  knife  (English  pattern.  A) 299 

88.  Blizard'.s  knife  (American  pattern,  B) 299 

89.  Blunt  gorget 299 

90.  Scoop 299 

91.  Lithotomy  forceps,  straight,  with  crossed  handles 300 


LIST   OF   ILLUSTIIATIONS. 


XV 


FIGURE  j,^„j. 

92.  Lithotomy  forceps,  curved,  with  crossed  handles 300 

93.  Metallic  tube,  with  obturator 300 

94.  Ilevcrse-flow  tube,  with  globular  head 300 

95.  Shirted  cannula 30i 

96.  Keith's  tenaculum ;jC,] 

97.  Pritchard's  anklets  and  wristlets ;if)l 

98.  Bony  outlet  of  the  pelvis 302 

99.  Diagrammatic  outlet  of  the  pelvis 303 

100.  Markoe's  median  lithotomy  staff 309 

101.  Little's  median  lithotomy  staff. 309 

102.  Little's  director 399 

103.  Petersen's  rectal  colpeurynter ,013 

104.  Cancer  of  the  kidney  in  a  child 349 

105.  Pediculi  pubis 359 

106.  Section  of  haematocele 371 

107.  Section  of  hydrocele 377 

108.  Simple  hydrocele  with  hernia 378 

109.  Congenital  hydrocele  with  congenital  hernia 383 

110.  Cupped  sound 444 

111.  Modification  of  Reverdin's  varicocele-needle 4.54 

112.  Fumigator 5gg 

113.  Berg's  case  of  syphilitic  dactylitis 635 

114.  McCready's  case  of  syphilitic  dactyhtis 636 


PART    I. 
DISEASES  OE  THE  GENITO-URIMRY  OEGAXS. 


CHAPTEE  I. 

DISEASES  OF  THE  PERIS. 

Anatomy. — Anomalies  ;  Double  Penis  ;  Absence  of  Penis.— Fracture,  Dislocation.— Cutaneons  Af- 
fections.—Tumors.— Cancer.— Amputation  of  Penis. — The  Prepuce  ;  Circumcision. — Phimosis  ; 
Remote  Results  of  Phimosis. — Paraphimosis. — The  Glans  Penis  ;  Herpes  Progenitalis,  Balanitis, 
and  Posthitis,  Vegetations,  Epithelioma. — The  Corpora  Cavernosa  ;  Inflammation,  Ossification, 
Calcification,  Gummy  Tumor,  Circumscribed  Chronic  Inflammation. 

The  penis  is  a  genital  organ.  Its  urinary  function  is  purely  sec- 
ondary. It  is  conformed  anatomically  to  subserve  the  genital  function. 
In  the  adult  it  measures,  when  at  rest,  from  the  root  of  the  scrotum 
to  the  meatus  urinarius,  from  two  and  a  half  to  four  inches  ;  when 
erect,  from  five  to  seven  inches.  It  consists  essentially  of  three  seg- 
ments— the  two  corpora  cavernosa,  lying  together  like  the  barrels  of  a 
gun,  and  the  corpus  spongiosum — like  the  ramrod — beneath  them,  the 
whole  surrounded  by  integument. 

The  Corpora  Caveristosa  arise  on  either  side  from  the  tuberosi- 
ties and  ascending  rami  of  the  ischium.  They  come  together  under 
the  symphysis  pubis,  and  continue  side  by  side,  forming  the  main 
bulk  of  the  penis.  They  terminate  anteriorly  in  a  conical  extremity, 
over  which  the  glans  jDcnis  (the  terminal  expansion  of  the  corpus 
spongiosum)  fits  like  a  cap.  There  is  no  vascular  communication  be- 
tween the  tissue  of  the  corpora  cavernosa  and  that  of  the  glans  penis, 
nor  with  that  of  any  part  of  the  corpus  spongiosum. 

Each  corpus  cavernosum  is  surrounded  by  its  own  fibrous  sheath — 
tunica  albuginea — which,  together,  are  so  dense  and  strong  that  they 
will  support  the  weight  of  the  cadaver  without  giving  way.*      The 

*  Cruveilhier,  "Traite  d'Anatomie  descriptive,"  Paris,  1S65,  vol.  ii,  part  i,  p.  386. 
1 


DISEASES  OF  THE  PENIS. 


sheath  is,  however,  plentifully  su}i})liod  with  clastic  fibers,  which  allow 
it  to  accommodate  itself  to  the  variable  size  of  the  organ.  The  parti- 
tion between  the  corpora  cavernosa  is  perforated  by  numerous  aper- 
tures, to  insure  thorough  and  symmetrical  erection.  The  tissue  projier 
of  the  corpora  cavernosa  is  known  as  spongy,  or  erectile.  Erection 
takes  place  when  thcarooh-e  of  this  tissue  become  distended  with  blood, 
as  shown  in  Fig.  2. 

TuE  Corpus  Spoxgiosum  URExnR.E  is  also  comiioscd  of  erectile 
tissue.     It  surrounds  all  that  portion  of  the  urethra  lying  in  front 

of  the  triangular  ligament,  anteriorly 
forming  the  cap  over  the  conical  ex- 
trenfity  of  the  united  cor2)ora  cavernosa 
— known  as  glans  penis — posteriorly 
terminating  in  the  bulb,  which  lies  just 
in  front  of  the  triangular  ligament  in 
the  angle  of  the  converging  crura  i)enis. 
The  Glans  Pexis  is  covered  by  a 
semi-mucous  membrane  endowed  with 
peculiar  sensibility,  especially  around 
the  raised  posterior  border — the  corona 
glandis.  The  epithelium  covering  the 
glans  is  line  ;  the  papillae  minute 
(Home)  ;  the  sebaceous  glands  (of  Ty- 
son) large  and  numerous,  and  most 
jalentiful  about  the  fra^ium.  These 
glands  secrete  the  white,  badly-smelling 
material  which  collects,  in  uncleanly 
persons,  behind  the  corona.  The  func- 
tion of  the  glans  penis  is  to  furnish  a 
soft-skinned  expansion  for  the  distri- 
bution of  the  terminal  filaments  of  the 
nerves  of  sexual  sensibility. 

One  important  function  of  the  cor- 
pus spongiosum  is  acquired  through  its  bulb — namely,  that  of  assisting 
in  the  expulsion  of  the  last  drops  of  urine  or  semen  from  the  urethra. 
The  prostate,  levator  ani,  and  deej)  urethral  muscles — especially  the 
compressor  iTrethrai — contract  upon  the  fluid  remaining  in  the  canal 
after  micturition,  in  that  spasmodic  etfort  called  by  the  French  the 
"coup  de  piston."  This  forces  the  last  few  drops  beyond  the  bulb  of 
the  urethra.  Now  the  middle  fibers  of  the  accelerator  urinoe — those 
which  surround  the  bulb  and  adjacent  portions  of  the  corpus  caverno- 
sum — contract  and  forcibly  drive  the  blood,  which  was  contained  in 
the  areolae  of  the  bulb,  forward  along  the  corpus  spongiosum,  forcibly 
distending  that  body,  and  thus  bringing  the  walls  of  the  urethra  more 
closely  into  contact  in  a  progressive  wave.     This  helps  to  explain,  as 


1 1  t;V*^^%v.i:r  \\&v~!v  w^^^^^^ 


Figs.  1,  2  (Cruveilhier). 

Transverse  Section  of  Penis.— Fig.  1. 
Flaccid.  Fig.  2.  In  erection.  1,2.  Dor- 
sal vein  and  artery.  3.  Erectile  ti.ssiie. 
4.  Tunica  albuginea.  5.  Integument. 
C.  Tunica  albugmea  of  corpus  spongi- 
osum.   7.  Erectile  tissue.    8.  Urethra. 


BUCK'S  FASCIA.  3 

shown  by  A.  Gucrin,*  why  the  last  few  drops  of  urine  do  not  escape 
promptly,  but  dribble  away  in  cases  of  organic  stricture  of  any  severity  ; 
for,  with  such  a  stricture,  the  areola)  of  the  erectile  tissue  become  more  or 
less  obliterated  at  the  constricted  point,  and  Ein  obstacle  is  formed  to  the 
free  passage  of  the  wave  of  blood  forward  along  the  corpus  spongiosum. 

The  three  erectile  bodies  which  have  been  briefly  described  arc  sur- 
rounded by  the  sheath  proper  of  the  penis — a  membrane  important  in 
its  pathological  relations,  and  sometimes  known  as  Buck's  fascia,  from 
the  distinguished  surgeon  who  first  accurately  described  it.  f  This  fascia 
may  be  said  to  arise  from  the  linea  alba  and  symphysis  pubis  by  a  tri- 
angular bundle  of  fibers  known  as  the  suspensory  ligament  of  the  penis. 
The  fibers  spread  out  upon  the  corpora  cavernosa,  extend  over  the 
conical  head  of  these  two  bodies,  and  are  at  this  point  firmly  attached 
to  the  under  surface  of  the  glans  penis,  which  may  be  removed  entire 
with  the  fascia.  The  sheath,  after  encircling  the  corpora  cavernosa, 
splits  into  two  layers,  to  embrace  and  form  a  sheath  for  the  corpus 
spongiosum.  The  fascia  is  attached  behind  along  the  rami  of  the  pubes, 
and  is  identical  with  the  deep  layer  of  the  superficial  fascia  of  the  peri- 
nasum,  curving  under  the  transverse  muscles,  and  finally  losing  itself  in 
the  anterior  layer  of  the  triangular  ligament.  The  cavity  of  this  fascia 
is  bounded  anteriorly  by  the  under  surface  of  the  glans  penis,  and  pos- 
teriorly by  the  triangular  ligament.  Its  boundaries  have  a  practical 
bearing  upon  the  burrowing  of  infiltrated  urine.  Urine  may  escape  out 
of  the  urethra,  and  yet  be  prevented  by  this  fascia  from  passing  the 
limits  above  described  for  an  indefinite  time,  unless  Eichet  J  is  correct 
in  stating  that,  at  the  root  of  the  penis  above,  the  fascia  can  not  be 
distinguished  from  that  covering  the  pubes — that  it  is  here  loose  in 
character — and  that  urine  may  escape  at  this  jDoiut  out  of  the  sheath 
into  the  areolar  tissue  of  the  abdominal  wall. 

The  lymphatics  and  veins  of  the  penis  run  along  the  dorsum  of  the 
member,  and  receive  in  their  course  branches  from  the  corpus  spongio- 
sum, which  encircle  the  penis  between  the  folds  of  Buck's  fascia.  The 
lymphatics  lead  mainly  to  glands  lying  along  and  above  Poupart's  liga- 
ment on  either  side.     The  arteries  come  from  the  internal  pudics. 

The  connective  tissue  which  attaches  the  integument  of  the  penis 
to  the  fascia  is  very  loose  and  elastic,  and,  like  that  of  the  eyelids,  does 
not  contain  fat. 

The  skin  of  the  penis,  except  that  it  tends  to  become  pigmented  af- 
ter puberty,  does  not  differ  essentially  from  ordinary  integument.  Over 
the  glans  penis  it  folds  back  upon  itself,  forming  a  non-adherent  sheath 
for  the  glans  (the  prepuce),  evidently  intended  to  preserve  the  delicate 
sensibility  of  this  portion  of  the  member. 

*  "Des  Retrecissemcnts  du  Canal  de  I'Uretre."   Mem.  de  la  Soc.  de  Chir.,  vol.  iv,  1857. 

f  "  Trans.  Am.  Med.  Ass.,"  vol.  i,  p.  367. 

X  "Traite  d'Anatomie  Medico-Chirurgicale,"  Paris,  1873. 


4  DISEASES   OF  THE   PENIS. 

The  Prepuce  is  composed  of  two  layers,  a  cutaneous  (external), 
and  a  more  delicate  semi-mucous  (internal).  The  point  of  junctiou  of 
these  two  is  called  the  orifice  of  the  prepuce.  Between  these  layers  is 
a  very  loose  aaid  elastic  connective  tissue,  without  fat,  which  allows  the 
two  surfaces  to  be  entirely  sciiarated  from  each  other,  and  the  pre- 
puce effaced,  by  drawing  back  the  integument  of  the  penis  until  the 
glans  is  entirely  uncovered.  The  mucous  layer  of  the  prepuce  is  sup- 
plied with  the  glands  of  Tyson.  It  is  much  less  clastic  than  the  cutane- 
ous layer. 

The  prepuce  is  attached  to  the  lower  angle  of  the  meatus  urinarius, 
or  orifice  of  the  urethra,  by  a  triangular  fold  of  mucous  membrane 
called  the  frajuum  preputii — analogous  to  the  fra?uum  lingua?. 

ANOMALIES    OF    THE   PENIS. 

Deformities  of  the  penis  are  constituted  by  abnormalities  in  some 
of  its  constituent  parts.  The  most  common  examples  will  be  men- 
tioned in  connection  with  these  parts.  As  anomalies  of  the  penis,  two 
conditions  demand  especial  notice — double  jjenis  and  absence  of  the 
penis.  Anomalies  in  size  occur,  as  when  the  penis  is  nine  or  ten  inches 
long  when  at  rest,  or  only  a  couple  of  inches  long  when  erect ;  but 
these  variations  are  very  uncommon. 

Double  Penis  is  excessively  rare.  It  is  analogous  to  double  uterus 
and  vagina  in  the  female,  but  by  no  means  so  common.  Undoubtedly 
it  is  not  so  uncommon  as  the  records  of  surgery  would  seem  to  imj^ly, 
for  the  existence  of  this  deformity  is  naturally  accompanied  by  an  ex- 
cessive sensitiveness  on  the  part  of  the  patient  which  leads  him  to  shun 
observation  and  comment ;  and,  as  the  defect  is  not  necessarily  accom- 
panied by  any  symptoms  affecting  the  general  health  injuriously,  the 
patient  does  not  voluntarily  subject  himself  to  the  inspection  of  a  phy- 
sician, and  thus  keejis  himself  out  of  the  books.  Case  I,  reported  by 
the  authors,  exemplifies  this  fact,  and  chance  alone  allows  it  to  be 
placed  on  record. 

A  case  of  this  anomaly  is  reported  by  Mr.  Ernest  Ilart*  (with  sev- 
eral plates  of  the  imticnt  in  different  positions),  in  the  person  of  a  well- 
formed,  healthy  man,  the  victim  of  a  monstrosity  by  foetal  inclusion. 
Between  his  thighs  there  gi-ew  a  third  thigh,  terminating  in  a  leg  and 
double  foot,  all  small  and  deformed.  In  front  of  this  thigh  there  was 
a  shrunken,  empty  scrotum,  bordered  on  either  side  by  a  well-devel- 
oped scrotum,  each  containing  one  testicle.  The  joenis  was  double, 
each  organ  being  well  formed  and  perfectly  developed.  They  were 
both  in  proper  j^osition,  each  measuring  four  and  a  half  inches  when 
pendent,  being  larger  than  normal.  The  left  was  the  larger  in  cir- 
cumference, and  appeared  to  have  become  so  by  being  used  in  j^refcr- 
ence  to  the  other.     Both  became  erect  at  the  same  time  under  excite- 

*  London  "Lancet,"  January,  1866,  p.  71. 


ACCIDENTS  TO   THE  PENIS.  5 

ment.  The  urine  or  the  semen,  as  the  case  mif(ht  be,  was  discharged 
simultaneously  by  both  organs.  In  the  first  edition  of  this  treatise  was 
published  a  typical  personal  case  of  double  penis  in  a  man  of  forty-two, 
who  presented  no  malformation  except  the  possession  of  two  well-formed 
virile  members,  one  of  which  was  imperforate,  its  urethra  opening  at 
tlie  peno-scrotal  angle,  A  case  of  double  penis  is  reported  by  Alan  P. 
Smith.*  The  patient  had  a  stone  in  one  of  his  bladders,  was^ut  and 
cured.     He  could  pass  water  from  either  bladder  at  will. 

Paetial  Development  of  the  Penis. — The  penis  is  sometimes 
defective  in  some  of  its  parts,  which  leads  to  a  more  or  less  pronounced 
twisting  of  the  organ.  This  deformity  is  generally  accompanied  by 
other  defects  (hypospadias). 

Absence  of  the  Penis. — A  case  of  congenital  absence  of  the  penis 
has  been  observed  by  Nelaton.f  The  scrotum  was  well  developed,  and 
contained  testicles.  The  child  urinated  through  the  rectum.  Another 
similar  case  has  been  reported  by  Goschler.  J  Eevolat  *  has  still  an- 
other. Bouteillier  ||  reports  an  infant  seemingly  without  penis.  Un- 
der the  skin  above  the  scrotum  a  movable  body  was  felt.  This  was 
liberated  by  incision  and  proved  to  be  a  rudimentary  penis. 

ACCIDENTS  TO  THE  PENIS  AS  A  WHOLE. 

Contusions. — The  escape  of  blood  under  the  skin  in  superficial 
contusions  of  the  penis  is  often  excessive,  on  account  of  the  laxity  of 
the  connective  tissue  and  the  large  size  of  the  superficial  veins. 
Deeper  contusions  give  rise  to  localized  swelling  from  circumscribed 
effusion  of  blood.  This  swelling  fluctuates,  increases  in  size  on  erec- 
tion, and  deforms  the  penis  more  or  less,  causing  it  sometimes  to  devi- 
ate from  its  natural  direction.  OiDening  into  such  a  collection  of  fluid 
is  not  to  be  thought  of,  as  it  might  give  rise  to  suppurative  inflamma- 
tion. If  the  contusion  be  severe  enough,  inflammation  of  the  corpora 
cavernosa  results,  ending  in  suppuration  or  gangrene.  Severe  con- 
tusions involving  the  urethra  may  lead  to  infiltration  of  urine  and 
loss  of  substance,  with  urethral  fistula. 

The  penis  is  sometimes  introduced  by  a  patient  into  a  ring.  The 
penis  swells,  the  patient  is  ashamed  to  seek  relief,  and  serious  inflam- 
matory mischief — even  gangrene,  urinary  fistula — may  ensue.  This  ac- 
cident is  rather  a  classical  one.  G-uillot  in  such  a  case,  where  the  ring 
was  of  gold,  conceived  the  happy  idea  of  dissolving  it  in  a  bath  of  mer- 
cury.    Demarquay  narrates  many  curious  instances  of  similar  charac- 

*  "  Trans.  Med.  and  Chir.  Faculty  of  Maryland,"  April,  1878. 
f  "Gaz.  des  Hop.,"  January  28,  1854. 

J  "  Vierteljahrschrift  fur  practische  Heilkunde,"  Prag,  part  iii,  185*7. 

*  "  Journal  de  Sedillot,"  tome  xxvii,  p.  3Y0 ;  and  Demarquay,  "  Maladies  Cliirurgical 
du  Penis,"  Paris,  1877,  p.  538. 

II  "  Union  m^dicale  de  la  Seine  inferieure,"  xl,  1875,  p.  27;  and  Demarquay,  op.  cif., 
p.  539. 


C  DISEASES   OF  THE   PENIS. 

tor  where  tlic  surgeon  has  been  eallod  to  get  the  penis  out  of  some  very 
extraordinary  positions. 

Treatment  of  contusion  consists  in  combating  inflammation,  em- 
ploying cokl,-  cYai)orating,  astringent  lotions  ;  later,  perliai)s,  com- 
pression, and  in  giving  the  absorbents  time  to  remove  the  effusion. 

AVouxDS. — The  penis  is  liable  to  be  -wounded  by  accident  or  design. 
In  the  latter  case  insanity,  or  the  melancholy  depression  often  attend- 
ing the  loss  of  self-respect  produced  by  masturbation,  is  usually  at 
fault,  and  induces  the  patient  to  mutilate  himself ;  or  the  injury  may 
be  inflicted  by  a  woman,  jealousy  being  the  motive. 

Superficial  cuts  are  unimportant ;  but  woiinds  extending  within  the 
sheaths  of  the  corpora  cavernosa  may  give  rise  to  troublesome,  possibly 
fatal  haemorrhage,  while  the  cicatrices  left  after  healing  may  distort 
the  penis  and  render  erection  imperfect  and  painful. 

In  a  case  of  traumatic  aneurism  of  the  penis  following  a  cut  by  a 
knife,  Malgaigne  *  had  to  tie  the  dorsal  artery. 

Treatment. — Clean  the  wound.  If  a  large  artery  is  spirting,  tie  it, 
but  let  the  oozing  points  alone.  Join  the  edges  as  accurately  as  pos- 
sible with  points  of  fine  suture  not  introduced  deeper  than  through  the 
fibrous  sheath.  Employ  moderate  pressure  in  dressing.  Erections, 
which  are  sure  to  occur  since  the  local  inflammation  induces  an  influx 
of  blood,  always  retard  healing. 

Even  in  cases  seemingly  desperate,  where  the  penis  has  been  almost 
wholly  severed  from  the  body,  an  attempt  should  be  made  to  save  it. 
A  remarkable  success  in  a  case  of  this  sort,  where  the  whole  penis  was 
severed,  except  a  portion  of  one  corpus  cavernosum,  is  related  by  Ar- 
taud.f  It  is  not  probable  in  such  a  recovery  that  the  erectile  power  is- 
restored. 

(For  injuries  involving  the  urethra,  refer  to  diseases  of  that  canal.) 

FEACTUBK  OF   THE  PENIS. 

When  the  fibrous  sheaths  of  the  corpora  cavernosa  are  ruptured  by 
sudden  forcible  flexion  of  the  erect  penis,  a  sort  of  fracture  of  the 
member  is  produced,  with  extensive  extravasation  of  blood — sometimes 
amounting  to  traumatic  aneurism.  Pain,  generally  present  as  a  symp- 
tom, is  sometimes  replaced  by  a  sensation  of  heat,  distention,  and 
weight.  Tlie  late  Valentine  Mott  J  reported  two  interesting  cases  of 
this  accident,  where  the  only  treatment  employed  was  rest  and  cold 
locally.  Both  cases  recovered  with  a  useful  organ  and  no  deformity. 
n.  A.  Veazie  *  reports  a  case  of  complete  fracture  of  the  penis  during 
intercourse.     Demarquay  has  cited  many  others. 

•-•• "  Revue  Mcdieo-Chir.  do  Paris,"  July,  1850,  p.  52. 

f  "Bull,  de  la  Soc.  de  Chir.,"  vol.  vii,  p.  451. 

X  '•Transactions  of  the  New  York  Academy  of  Medicine,"  vol.  i,  part  i,  1851,  p.  99. 

*  "New  Orleans  Medical  and  Surgical  Journal,"  1881. 


DISLOCATION   OF   THE   PENIS.  7 

Treatment. — A  silver  or  stout  woven  catheter,  strong  enough  to 
resist  lateral  comj)ression,  is  first  passed  into  the  bladder  to  insure  the 
patulousness  of  the  urethra  when  the  degree  of  swelling  threatens 
closure.  Upon  this  the  penis  may  be  compressed  with  adhesive  straps 
and  cold  applied.  A  risk  to  the  patient  in  this  condition  is  that  ex- 
cessive tension  from  internal  hasmorrhage  may  arrest  circulation  and 
produce  gangrene — a  very  rare  accident — or  damage  miglit  come  from 
urinary  infiltration  when  the  urethra  is  involved,  as  in  Dittel's  case. 
In  the  latter  contingency,  prompt  and  free  incision  is  indispensable  ; 
with  threatened  gangrene,  antiseptic  incision  would  be  justifiable,  the 
bleeding-point  being  controlled  by  ligature  or  cautery.  When  the 
swelling  is  not  excessive,  an  evaporating  lotion  is  all  that  is  required, 
and  in  from  three  to  eight  weeks  the  patient  is  usually  well. 

After  recovery  an  indurated  spot  may  remain  to  mark  permanently 
the  site  of  the  injury,  making  erection  perhaps  imperfect  or  painful, 
and  interfering  with  sexual  intercourse. 

PRACTUBE  OF  THE  CORPUS  SPONGIOSUM. 

The  corpus  spongiosum  alone  may  be  fractured.  This  is  generally 
occasioned  by  ''breaking  the  chordee"  in  gonorrha3a  by  violently 
straightening  the  organ  during  erection.  The  inflamed  tissue  gives 
way,  yielding  urethral  haemorrhage  as  an  immediate  and  traumatic 
stricture  a  remote  result. 

The  healthy  corpus  spongiosum  may  be  fractured  during  erection. 
Dittel*  gives  such  a  case.     The  authors  have  seen  another,  f 

DISLOCATION  OF  THE  PENTS. 

In  violent  contusions  involving  the  jDenis,  particularly  when  the 
integument  is  dragged  upon,  as,  for  instance,  when  the  clothes  are 
caught  and  torn  away  upon  a  revolving  wheel,  the  whole  penis  may  be 
shot  out  of  its  investing  cutaneous  sheath  and  lodged  in  the  scrotum, 
perinffium,  groin,  or  under  the  integument  of  the  abdomen,  according 
to  the  direction  of  the  force.  In  such  cases  the  semi-mucous  mem- 
brane of  the  prepuce  gives  way  either  at  the  preputial  orifice  or  just 
behind  the  corona.  A  number  of  instances  of  this  curious  luxation 
have  been  recorded.  The  penis  is  usually  not  discovered  until  reten- 
tion of  urine  or  the  passage  of  urine  by  some  opening  at  a  distance 
from  the  preputial  orifice  directs  attention  to  the  contused  genitals, 
when  the  penis  is  found  to  be  only  a  sheath  of  integument  containing 
clotted  blood.  Sometimes  it  has  been  difficult  to  find  the  penis  at  all ; 
but  an  intelligent  search  will  always  reveal  it,  and  then  the  surgeon's 
obvious  duty  is  to  replace  it  in  its  sheath,  incising  the  integument 
about  the  root  of  the  sheath  as  far  as  may  be  necessary  to  attain  the 
desired  result. 

*  "  Wien.  med.  Blatter,"  1885,  No.  2.        f  "Van  Buren  and  Keyes,"  first  ed.,  p.  7.. 


8  DISEASES  OF  THE  PENIS. 

In  dislocation  tlie  urethra  is  often  ruptured  low  down,  and,  after 
the  organ  has  been  replaced  in  its  sheath,  external  perineal  section 
without  a  guide  nuiy  bo  called  for,  an  operation  particularly  suitable 
in  view  of  the  traumatic  stricture  which  is  inevitable.  In  this  wa}' 
the  continuity  of  the  canal  is  restored. 

In  one  case  in  an  infant  of  six  years,  Xelaton  *  reduced  a  dislocated 
penis  through  the  preputial  oritice  by  means  of  Coo2)er's  aneurism 
needle,  assisting  its  hook-action  by  external  manipulation. 

CUTANEOUS  AFFECTIONS  OF  THE  PENIS. 

ilany  ordinary  cutaneous  aflfections  also  involve  the  integument  of 
the  penis.  Venereal  ulcers  are  very  common  here.  Elephantiasis 
usually  invades  the  scrotum  primarily.  In  phlegmonous  erysipelas 
early  and  very  extensive  parallel  incisions  in  the  long  axis  of  the  organ 
may  be  necessary  to  prevent  gangrene  of  the  skin  and  extensive  denu- 
dation of  the  penis. 

LYMPHATIC  AFFECTIONS  OF  THE  PENIS. 

Inflammatory  lymjihangitis  may  complicate  a  Yariety  of  lesions. 
The  venereal  varieties  will  be  described  in  their  projDer  i^lacc.  Simple 
inflammatory  lymphangitis  behaves  like  a  mild  erysipelas  and  needs  no 
description.  It  may  occur  spontaneously,  but  most  often  complicates 
gonorrhoea  or  chancroid.  It  yields  to  local  cooling  and  astringent  lo- 
tions. Occasionally  it  goes  on  to  a  gelatiniform  oedema  quite  dense 
and  hard,  a  sort  of  false  elephantiasis,  affecting  chiefl}^  the  prepuce, 
and  this  condition  again  is  sometimes  complicated  by  little  solid  promi- 
nences, which  are  fistula  communicating  with  the  lymphatic  plexus. 
Sometimes  they  discharge  sero-pus.     They  may  be  cured  by  excision. 

The  lymi^hatic  vessels  of  the  penis  are  sometimes  found  dilated  as 
a  result  of  no  obvious  cause. 

I  have  seen  quite  a  number  of  these  cases,  the  dilated  vessel  being 
thin-walled,  translucent,  and  varying  in  size  up  to  a  half-inch  in  di- 
ameter. I  have  seen  the  dilated  vessel  encircle  the  i)enis  behind  the 
corona,  and  at  other  times  have  noted  its  track  for  a  short  distance  lat- 
erally along  the  penis,  and  I  have  noted  it  as  an  oval  cystic  pouch 
hanging  from  the  end  of  the  prepuce.  I  have  never  attempted  to  cure 
a  case,  as  there  were  no  symptoms. 

Demarquay  f  has  an  interesting  section  upon  this  subject.  Ilugier  J 
gives  an  example  where  there  were  several  dilated  trunks  which  yielded 
pure  lymph  on  puncture.  Bean  in  such  a  case  passed  a  seton,  left  it 
in  a  few  minutes,  and  accomj)lished  a  cure  by  adhesive  inflammation. 
A  case  reported  by  Friedrich  is  quoted  by  Busey,*'  where,  after  chan- 

*  "Gaz.  des  H&p.,"  18.50,  p.  341.  f  Op.  cU.,  p.  306. 
X  "  Bull,  dc  la  Soc.  de  Chir.,"  1851-'') 2,  p.  592. 

*  "  Congenital  Occlusion  and  Dilatation  of  Lymph  Channels,"  New  York,  1878,  p.  175. 


TUMORS  OF   TUB   TENIS.  9 

croid,  the  inguinal  glands  inflamed  and  the  penis  became  turgesccnt. 
A  dull-white,  whoy-likc  vessel  appeared  around  the  base  of  the  corona 
glandis,  receiving  a  number  of  other  anastomotic  vessels,  and  termi- 
nating in  a  median  large  trunk  on  the  dorsum  penis.  Peri -glandular 
suppuration  occurred  in  the  groins,  the  abscesses  were  opened,  and 
with  the  healing  of  the  latter  the  enlarged  lymphatic  trunks  gradu- 
ally disappeared. 

TUMORS  OF  THE   PENIS. 

Fatty,  fibrous,  cystic,  erectile,  melanotic,  and  other  tumors  are 
occasionally,  but  very  rarely,  found  on  the  i^enis.  Their  removal  is  a 
question  of  Judgment  involving  a  recognition  of  the  function  of  the 
penis  as  an  intromittent  organ,  and  the  possible  loss  of  this  function 
from  the  formation  of  cicatrix. 

Cancee  of  the  penis,  except  epithelioma,  described  under  diseases 
of  the  glans  penis,  is  exceedingly  rare.  The  medullary  variety  is  some- 
times seen,  especially  in  boys,  following  injury  of  the  part.  It  grows 
rapidly  in  a  lobular  form,  unequally  in  the  corpora  cavernosa.  It  in- 
volves the  glans,  and  sprouts  out  under  the  prepuce.  The  veins  of 
the  penis  become  larger  and  tortuous.  The  distention  of  the  common 
fibrous  sheath  of  the  penis,  by  the  rapid  growth  of  the  new  formation 
within  it,  may  compress  the  urethra,  and  make  retention  of  urine  im- 
minent, calling  for  external  perineal  urethrotomy  to  relieve  the  blad- 
der, as  occurred  in  a  case  of  a  boy  under  the  charge  of  Dr.  Weir,*  at 
St.  Luke's  Hospital,  in  this  city.  The  pain  of  this  form  of  cancer  is 
severe.  Some  of  the  bulging  prominences  along  the  penis  are  very 
soft,  and  give  a  fallacious  impression  of  fluctuation,  which  is  very 
marked.  Local  heat  is  increased,  and,  as  the  disease  may  develop 
not  long  after  injury  to  the  part,  the  question  of  suppuration  of  the 
corpora  cavernosa  may  present  itself  to  the  young  surgeon.  The 
inguinal  glands  soon  become  involved,  the  patient  emaciates  rapidly 
and  dies. 

Prognosis  is  the  worst,  and  amputation,  the  only  resource,  is  not 
to  be  thought  of,  unless  the  growth  be  very  recent,  and  involve  only 
the  fore  part  of  the  member.  Eelapse  would  even  in  such  cases  be 
almost  inevitable. 

Cutaneous  horns  of  large  size  have  been  found  upon  the  penis 
growing  from  the  glans  or  the  integument.  Brinton,  of  Philadelphia, 
has  described  a  curious  case,  referring  in  his  article  to  all  previously 
recorded  instances  of  the  affection,  f     Consult  also  Demarquay.  J 

AMPUTATION  OF  THE  PENIS. 

In  amputating  the  penis,  as  much  of  the  organ  should  be  spared  as 
possible.     If  it  is  divided  too  near  the  root,  it  will  retract  behind  the 

*  "  American  Journal  of  the  Medical  Sciences,"  April,  1876,  p.  407. 
f  "  Medical  News,"  Philadelphia,  August,  18S7.      %  Op.  cit.,  p.  326. 


10  DISEASES  OF   TUE   PEXIS. 

sympli3'sis,  unless  care  be  taken  to  prevent  it,  and  render  it  diflScult 
to  control  haemorrhage.  Therefore,  where  the  section  must  be  low,  a 
stout  ligature  may  be  passed  behind  the  proposed  limit  of  operation, 
through  some  part  of  the  sheath  of  the  penis,  as  a  preliminary  step, 
before  cutting  into  the  corpora  cavernosa,  or  the  root  of  the  penis 
may  be  transfixed  by  two  long  acujnincture  needles  passed  at  right 
angles.  When  amputation  is  made  low  down,  the  urethra  should  be 
dissected  loose  toward  the  bulb,  and  brought  out  into  the  perineum 
behind  the  scrotum  to  guard  against  soiling  the  clothes  during  urina- 
tion. 

Only  under  rare  conditions  is  partial  amputation  of  the  penis  al- 
lowable. It  may  sutUce  where  cancer  is  confined  to  the  glans  penis, 
but  generally  the  whole  organ  has  to  be  sacrificed  if  any  amputation 
is  performed.  For  partial  amputation,  the  skin  should  be  incised  at 
a  point  somewhat  lower  than  it  is  desired  to  divide  the  body  of  the 
penis,  as  the  latter  shrinks  after  section.  The  corpora  cavernosa 
should  be  severed  with  one  stroke  of  the  knife.  The  haemorrhage  is 
free,  and  many  spirting  points  will  require  ligature.  The  arteries  are 
liable  to  retract  into  the  tissue  of  the  corpora  cavernosa,  and  the  for- 
ceps must  be  slender-pointed  and  grasp  well  to  seize  them.  Some- 
times they  can  not  be  pulled  out.  Pressure  and  cold  will  arrest  ooz- 
ing, but  some  persulphate  of  iron  should  be  at  hand  to  be  used  if 
necessary.  If  there  is  tissue  enough,  the  urethra  should  be  divided 
about  half  an  inch  in  front  of  the  point  of  j)roposed  section  as  the 
first  step  of  the  operation  after  dividing  the  skin.  When  all  bleeding 
has  been  quieted,  the  urethra  is  slit  into  two  equal  lateral  flaps,  and 
these  are  united  by  many  points  of  fine  suture  to  the  skin,  over  the 
corpus  spongiosum,  on  either  side.  In  case  there  is  not  enough  tissue 
to  spare,  the  expedient  of  Mr.  Teale*  may  be  resorted  to,  which  consists 
in  slitting  the  under  surface  of  the  uretlira  after  amputation,  to  the 
extent  of  about  two  thirds  of  an  inch,  and  uniting  the  mucous  mem- 
brane to  the  skin  on  each  side  of  the  slit  by  suture.  If  the  urethra 
is  not  especially  attended  to,  stricture  of  a  very  serious  character  is 
sure  to  follow  cicatrization.  If  the  precaution  has  been  omitted  at 
the  time  of  operating,  and  stricture  has  resulted,  it  may  be  dealt  with 
subsequently  by  Teale's  method. 

Galvano-cautery  may  be  employed  in  amputation  of  the  penis,  or 
the  ecraseur  of  Chassaignac,  or  Maisonneuve's  modification  with  a 
stout  wire,  and  the  urethra  treated  by  Teale's  method.  After  the 
ecraseur,  however,  sharp  bleeding  will  sometimes  come  on  in  a  few 
hours.  As  a  rule,  each  of  these  latter  methods  is  comparatively  blood- 
less, but  after  any  operation  there  may  be  recurrent  hremorrhage 
shortly,  accompanied  by  a  tendency  to  erection.  Properly  applied 
pressure  will  arrest  it.     An  excellent  historical  chapter  upon  ampu- 

*  "  ilcdical  Times  and  Gazette,"  vol.  xix,  p.  354. 


THE  rREPUCE.  11 

tation  of  the  penis  is  given  by  Louis  Jullicn*  in  ]iis  '^Tlicsis."     Cu- 
badc  has  contributed  f  some  points. 

When  it  is  desired  to  remove  the  entire  penis,  including  the  bulb 
of  the  urethra,  the  method  first  used  by  Delpcche  (1832),  then  by 
Lallemand,  Roux,  and  Bouisson,  is  a  good  one,  namely,  as  a  first  step 
in  the  operation,  to  split  the  raphe,  inclosing  one  testicle  in  each  half. 
Then  Cabade's  process  may  be  employed,  making  a  houtonniere  in  the 
membranous  urethra^  incising  the  integument  above  and  around  the 
root  of  the  penis,  and  taking  ofl:  each  crus  penis  separately  with  the 
ecraseur  passed  through  the  boutonnure  between  the  crura  penis.  Of 
course,  if  the  bulb  and  a  portion  of  the  urethra  can  be  spared  for  trans- 
plantation in  the  perinseum,  so  much  the  better.  In  such  case  a  por- 
tion of  the  sides  of  the  scrotum  may  be  united  above  the  orifice  of  the 
transplanted  urethra  in  such  a  way  as  to  form  nymphse  in  front  (as 
Howe  has  called  them),  which  during  urination  direct  the  stream 
downward  and  backward.  Howe  first  did  this ;  later.  Fowler  J  of 
Brooklyn.  Instead  of  using  the  ecraseur  upon  the  crura  sejoarately, 
it  is  more  surgical,  but  more  difficult  on  account  of  hasmorrhage, 
after  sjDlitting  the  scrotum  and  separating  the  urethra,  to  dissect  out 
each  crus  penis  separately,  and  remove  it  entire  from  its  insertion  along 
the  ischial  and  pubic  rami.  With  forcipressure  forcejos  this  manoeuvre 
is  perfectly  practicable,  and  the  amputation  of  the  penis  thus  becomes 
complete.     The  inguinal  glands,  if  implicated,  should  be  removed. 

THE   PEEPXTCE. 

Defoemities. — Practically,  the  deformities  of  the  foreskin  (phimo- 
sis and  atresia  of  the  orifice  excepted)  are  unimportant.  The  prepuce 
is  sometimes  bifid,  enlarged  into  a  pouch,  redundant,  projecting  half 
an  inch  or  more  beyond  the  apex  of  the  glans,  or  only  rudimentary 
from  arrest  of  develojiment.  Between  the  two  latter  limits  it  may  be 
of  any  length,  covering  more  or  less  of  the  glans.  When  the  prepuce 
is  deficient,  the  epithelium  of  the  uncovered  glans  penis  becomes  hard 
and  tough,  more  nearly  resembling  ordinary  cuticle.  Under  these 
circumstances  the  sensibility  of  the  part  is  diminished,  but,  at  the 
same  time,  it  is  rendered  less  liable  to  become  excoriated  or  to  take 
on  inflammation.  Hence,  absence  of  the  prepuce  is  not  to  be  re- 
gretted, and  the  operation  for  its  restoral,  postheoplasty,  need  not  be 
touched  upon.  Dieffenbach  performed  it  once  on  account  of  neu- 
ralgia of  the  glans  penis. 

Excessive  length  of  the  prei)uce  may  demand  operative  interfer- 
ence. Moderate  length  alone,  however,  can  hardly  be  said  to  consti- 
tute a  defect,  and  may  be  left  unmolested  unless  complicated  by 
induration,  thickening,  or  a  contracted  preputial  orifice  (phimosis), 

*  Paris,  1873.  f  "  Bull,  de  la  Soc.  de  Chir.,"  tome  iv,  187S,  p.  500. 

X  "Annals  of  Anatomy  and  Surgery,"  September,  1881,  p.  102. 


12 


DISEASES  OF  THE   PENIS. 


or,  unless  it  becomes  troublesome,  by  getting  constantly  inllamccl,  or 
occasions  and  keeps  uj)  balanitis.  Great  length  of  the  prepuce  is  some- 
times the  result  of  constant  traction,  as  in  children  with  stone. 


CIRCUMCISION. 

In  this  operation  the  orilice  of  the  prejiuce,  with  more  or  less  of  its 
mucous  and  cutaneous  layers,  is  cut  away.  According  to  Hebrew 
chronologists,  circumcision  was  instituted  as  a  religious  rite  by  Abra- 
ham in  the  year  of  the  world  2059 — nineteen  hundred  and  forty-one 
years  before  Christ.  Several  Eastern  nations  still  practice  it  as  a 
hygienic  measure.  The  chosen  people  preserve  the  custom  as  a  re- 
ligious ceremony,  performing  it  on  the  eighth  day. 

Few  operations  in  surgery  have  received  more  modifications  than 
this  simple  one  of  ablation  of  the  prepuce.  The  indication  is  to  re- 
move the  orilice  of  the  prepuce  and  all  redundant  tissue,  and  to  insure 
looseness  of  what  is  left.     This  may  be  accomplished  as  follows  : 

If  phimosis  exists,  first  insert  a  well-oiled  probe  into  the  preputial 
cul-de-sac,  and  with  it  sweep  the  entire  surface  of  the  glans  to  detect 
adhesions  and  break  them  up,  if  they  are  not  too  firm.  Then  mark 
oflf  with  an  aniline  pencil  the  limits  of  the  integument  which  it  is 
proposed  to  remove.  This  line  should  follow  the  curve  of  the  corona 
glaudis  at  a  short  distance  in  front  of  it,  while  the 
member  is  lying  at  rest.  !Evow  seize  the  redundant  ^Dre- 
puce  laterally  on  both  sides,  and  draw  it  forward  until 
the  circumcision  forcej^s  can  be  locked  in  such  a  manner 
upon  the  redundant  integument  that  the  aniline  line 
shall  lie  just  in  front  of  the  closed  blades,  taking  care 
not  to  include  the  tip  of  the  glans  in  the  grasp  of  the 
forceps.  To  do  this  the  forceps  must  not  be  applied 
transversely  to  the  long  axis  of  the  ]ienis,  but  obliquely, 
and  sometimes  it  is  necessary  to  roll  the  integument  a 
little  forward  and  not  to  catch  the  preputial  orifice  as  a 
point  of  traction  in  order  to  get  the  aniline  line  outside 
of  the  forceps.  With  scissors  curved  on  the  flat,  the 
outlying  portion  of  prepuce  may  now  be  cut  away. 

This  method  of  operating  removes  two  dangers.    The 
aniline  line  insures  a  removal  of  exactly  that  portion  of 
integument  which  it  is  desired  to  take  away,  and  the 
possibility  of  cutting  away  a  band  of  integument  of  in- 
definite dimensions  is  averted.     Moreover,  a  loose  oval 
orifice  is  insured  for  the  new  prepuce,  and  the  narrow,  circular,  con- 
stricting band  of  cicatrix,  sometimes  left  by  the  old  operation  to  re- 
new the  deformity  after  healing,  becomes  impossible.*    Furthermore, 

*  I  have  more  than  once  been  called  upon  to  relieve  by  operation  a  phimosis  resulting 
from  a  former  operation  (Keyes). 


circumcision. 


CIIICUMCISION.  13 

by  so  placing  the  forceps,  the  frcnum  and  its  artery  arc  generally 
spared.  Fenestration  of  the  forceps  is  not  desirable,  because  the  mu- 
cous membrane  has  to  be  cut  away,  and  sutures  should  not  be  placed 
until  this  has  been  done.  After  the  forceps  has  been  removed,  the 
inner  layer  of  the  prepuce  is  to  be  slit  down  to  the  corona  upon  the 
dorsum  of  the  glans,  and  the  entire  mucous  membrane  to  be  trimmed 
away  on  either  side  up  to  the  frenum,  leaving  only  enough  tissue  to 
serve  to  hold  the  sutures.  The  redundant  tissue  about  the  frenum  is 
appropriately  trimmed,  bleeding  points  attended  to  by  pressure  or 
torsion,  and,  if  necessary,  to  insure  thorough  looseness  of  the  raw  border 
of  the  integument,  a  liberating  incision  is  made  directly  down  the 
dorsum  of  the  penis,  for  a  quarter  of  an  inch  or  more. 

It  may  be  necessary  to  dissect  away  old  adhesions  between  the  mu- 
cous layer  of  the  prepuce  and  the  glans  penis,  but  they  will  generally 
tear.  Ligatures  are  rarely  necessary.  When  required,  fine  catgut  may 
be  used,  but  it  is  better,  rather  than  to  use  ligatures,  to  catch  bleeding 
points  in  the  grasp  of  the  final  horse-hair  sutures,  so  that  the  same 
traction  which  unites  the  wound  may  also  constrict  the  bleeding  point. 
The  wound  may  be  washed  with  a  mild  bichloride  solution,  but  such 
disinfection  does  not  seem  to  be  necessary  ;  primary  union  seems  always 
to  occur. 

In  the  infant  no  suture  is  required.  The  parts  coapt  naturally, 
and  healing  is  accomplished  usually  in  about  forty-eight  hours.  In 
the  adult  healing  is  greatly  facilitated  by  numerous  sutures  to  keep 
the  cut  edges  in  apposition,  for  the  operation  usually  produces  a 
tendency  to  erection,  and  erection  disturbs  the  relation  of  the  j)arts. 
Erection  does  not,  however,  interfere  with  healing  in  the  least,  if  the 
oval  line  of  incision  is  very  loose.  No  tension  is  brought  upon  the 
stitches  by  any  amount  of  erection,  and  I  do  not  consider  it  of  any  im- 
portance, or  to  be  guarded  against  in  any  way. 

In  my  hands,  rather  coarse  horse-hair  has  proved  the  best  material 
with  which  to  suture  the  cut  edges.  The  first  suture  should  be  ap- 
plied at  the  raphe,  and  then  all  the  others  are  certain  to  fall  naturally 
in  place.  As  many  as  twenty-five  sutures  may  be  applied  when  the 
wound  is  long.  Each  one  should  take  in  the  least  possible  portion  of 
integument  on  the  one  side  and  of  mucous  membrane  on  the  other. 
The  first  knot  is  to  be  drawn  very  tightly  to  cut  into  the  tissues,  the 
second  loosely,  to  avoid  severing  the  first.  The  ends  of  the  suture 
are  to  be  cut  off  about  an  inch  long.  This  prevents  the  wound  from 
rolling  in  during  the  swelling  of  the  first  two  days,  and  there  are  no 
short,  sharp  little  points  left  to  prick  the  tissues  during  the  displace- 
ment caused  by  swelling. 

The  member  is  now  washed,  dried,  and  may  be  inserted  into  a  large 
roll  made  by  tying  up  a  towel  with  a  string,  and  lashing  this  thick  jDer- 
forated  disk  by  cords  passed  about  the  thighs  and  body.     Against  this 


14  DISEASES  OF  TBE  TEXIS. 

thickened,  perforated  disk  the  penis  rests  on  the  inside.  It  is  kept  from 
contact  with  the  patient  or  the  bed-clothing,  and  in  the  partially  erect 
joostnre  most  suitable  to  prevent  oedema.  It  is  not  my  custom  to  apply 
any  description  of  dressing  whatsoever,  or  any  wrappings,  to  the  penis. 
In  a  child  that  wears  a  napkin  I  still  use  the  perforated  piece  of  lineu 
folded  over  the  penis  and  well  greased — simply  to  prevent  adhesion 
of  the  wound  to  the  diaper. 

No  further  attention  surgically  is  required.  The  horse-hair  su- 
tures spontaneously  cut  their  way  out  without  suppuration,  and  come 
away  in  the  scab.  On  the  third  day,  as  the  swelling  subsides,  the  long 
ends  of  the  horse-hair  sutures  may  be  trimmed  down  close  to  the  scab, 
to  prevent  their  being  pulled  upon  during  the  motions  of  the  patient. 
Eest  in  bed,  although  not  essential,  is  desirable,  if  prompt  union  is 
expected.  Union  by  first  intention  may  be  counted  upon,  and  the 
patient  may  go  about  practically  well  on  the  fourth  to  the  eighth  day, 
according  to  his  healing  capacity.  An  opiate  for  sleep  and  a  laxative 
are  the  only  medicines  usually  required.  The  diet  need  not  be  modi- 
fied. It  is  better  to  perform  this  operation  with  the  aid  of  ether.  I 
have  succeeded  moderately  well  by  injecting  twenty  drops  of  a  four- 
per-cent  solution  of  the  hydrochlorate  of  cocaine  between  the  layers  of 
the  foreskin  a  few  minutes  before  commencing  the  operation,  but  the 
effect  is  not  all  that  could  be  desired. 

When  from  previous  disease,  specific  cause,  or  otherwise,  union  by 
first  intention  is  not  obtained,  the  granulating  wound  is  to  be  treated 
on  ordinary  surgical  principles,  with  stimulating  applications  in  lotion 
or  ointment. 

The  other  Operations  for  overcoming  tightness  require  but 
slight  mention.  A  very  common  and  sufficiently  good  operation, 
where  the  prepuce  is  tight  but  not  redundant,  consists  in  making  one 
incision  along  the  dorsum  of  the  prepuce,  including  both  layers,  from 
the  orifice  to  the  base  of  the  corona,  and  uniting  the  two  layers  of  pre- 
puce on  either  side.  It  is  better  to  trim  off  the  corners.  Several  par- 
tial incisions  at  different  points  have  been  advocated.  Lister  approves 
this  method. 

Another  method  consists  in  nicking  the  mucous  membrane  at  the 
orifice,  pulling  the  prepuce  back,  until  the  orifice  again  becomes  tight, 
and  then  nicking  again,  and  so  on,  until  the  mucous  layer  is  sufficiently 
loose  to  glide  easily  over  the  corona.  Again,  where  the  prepuce  can 
be  retracted  when  the  penis  is  not  erect,  the  mucous  membrane  alone 
has  been  divided  upon  a  director,  the  prepuce  being  pulled  back  and 
the  cut  made  along  th6  dorsum  of  the  penis,  from  just  behind  the 
corona  to  the  junction  of  mucous  membrane  with  skin.  The  longitu- 
dinal incision  is  to  be  united  transversely.  Both  these  operations  will 
yield  imperfect  results  unless  the  skin  be  very  loose  and  the  entire  strict- 
ure situated  in  the  mucous  membrane,  which  is  not  always  the  case. 


MORBID   CONDITIONS   OF   TILE   TREPUCE.  15 

The  frceniim  maybe  too  short  and  require  division — readily  ofTocted 
with  a  sharp-pointed  bistoury,  the  artery  being  twisted  or  tied, 

Compressed  sponge  (Montcggia)  and  laminaria  digituta  have  been 
used  to  distend  a  tight  preputial  orifice,  but  the  cases  Avliere  this  treat- 
ment yields  anything  more  than  temporary  relief  must  be  few. 
Forcible  dilatation  *  has  been  employed  by  Nelaton,  Cruise,f  of  Dub- 
lin, and  others,  -and  favorable  reports  rendered.  A  two-  or  three- 
bladed  forceps,  made  expressly  for  the  purpose,  is  inserted,  closed, 
into  a  tight  preputial  orifice,  the  desired  amount  of  dilatation  being 
first  decided  upon,  and  then,  by  suddenly  separating  the  blades  of  the 
Instrument,  dilatation  (perhaps  more  properly  divulsion)  is  effected. 
The  prepuce  is  now  retracted  and  held  behind  the  corona  for  from 
twenty-four  to  forty-eight  hours,  water-dressing  only  being  employed. 
This  treatment  might  be  useful  in  some  cases,  but  the  application 
of  circumcision  is  universal.  The  elastic  ligature  has  had  some  ad- 
vocates (Hue,  of  Eouen).J 

MORBID  CONDITIONS  OF   THE  PREPUCE. 

Phimosis  ((^t/^ow,  /  Mncl)  exists  where  the  orifice  of  the  prepuce  is 
so  small  that  the  glans  penis  can  not  be  uncovered.  The  orifice  of  the 
prepuce  may  be  congenitally  absent  (atresia  prejoutii).  Phimosis  is 
congenital  or  acquired,  simple  or  inflammatory,  or  complicated  by 
other  diseases  or  by  adhesions. 

With  very  young  children,  phimosis  is  so  common  that  it  may  be 
considered  normal.  The  foreskin  of  a  child  is  developed  out  of  all 
proportion  to  the  rest  of  the  penis,  taking  the  member  after  jjuberty 
as  a  standard  of  comparison.  This  long  prepuce  is  often  a  source  of 
anxiety  to  young  mothers,  who  fear  that  the  condition  may  remain 
permanent.  They  may  be  assured  that  it  will  right  itself  as  the 
child  grows.  Whenever  the  prepuce  can  be  retracted  sufl&ciently  to 
allow  the  glans  to  be  seen,  there  need  be  no  anxiety  about  the 
future  ;  the  preputial  orifice  will  enlarge  sufficiently  before  or  at 
puberty.  This  anxiety  is  similar  to  that  of  mothers  about  short  frse- 
num  linguae. 

A  positive  indication  for  operation,  in  the  case  of  a  child,  does  exist, 
however,  where  the  preputial  orifice  is  smaller  than  that  of  the  urethra. 
This  condition  is  known  to  exist  when  the  prepuce  "  balloons"  during 
micturition,  for  the  urine  flows  into  its  cavity  more  rapidly  than  it  can 
escape  from  its  orifice.  In  these  cases  the  retention  of  a  drop  or  two 
of  urine  in  the  cavity  of  the  prepuce,  after  each  act  of  urination,  must, 
sooner  or  later,  lead  to  inflammation  of  one  or  both  of  the  mucous  sur- 
faces, and  may  give  rise  to  severe  suppurative  inflammation,  the  growth 

*  Known  as  Nekton's  operation,  "  Gaz.  dcs  Hop.,"  31,  1S68. 

t  "  Dublin  Quarterl}',"  xlviii,  p.  482. 

X  "  Bull,  de  la  Soc.  de  Chir.,"  tome  iv,  1878,  p.  682. 


16  DISEASES   OF  THE   PEXIS. 

of  vegetations,  adhesions  of  the  prepuce  to  the  ghms,  formation  of  pre- 
putial stone,  or  incrustation  of  ghms. 

Wlien  the  prepuce  is  too  tight  in  the  aOult,  an  operation  may  be 
called  for  as  a  prophylactic  against  future  disease,  although  phimosis, 
strictly  speaking,  does  not  exist.  Here  the  collection  of  smegma,  or 
an  attack  of  herpes,  may  give  rise  to  an  inflammation  Avhich  will  ne- 
cessitate an  operation  under  unfavorable  circumstances.  Again,  if  an 
individual  with  tight  prepuce  gets  chancre,  chancroid,  or  gonorrha3a, 
serious  inflammatory  complications  are  liable  to  arise. 

Phimosis  may  be  brought  about  secondarily  through  induration 
and  inelasticity  of  the  skin,  caused  by  frequent  attacks  of  preputial 
inflammation.  AVheu  such  inflammation  is  prolonged  in  the  chronic 
state,  the  meshes  of  the  connective  tissue,  at  first  distended  with  serum, 
become  secondarily  thickened  and  hypertrophied,  sometimes  to  an  ex- 
tent almost  worthy  of  the  name  of  elephantiasis.  The  serum  is  ab- 
sorbed and  its  place  supplied  by  a  hyperplasia  of  connective  tissue, 
leaving  a  thick,  long,  indurated,  inelastic  iirepuce,  interfering  not 
only  with  sexual  intercourse,  but  sometimes  even  with  urination. 

Another  common  cause  of  acquired  phimosis  is  the  cicatrization  of 
multiple  chancroid  around  the  orifice  of  the  prepuce.  Bourgadc*  al- 
ludes to  diabetes  as  a  cause  of  phimosis  (four  cases).  Verneuil  has  seen 
two,  and  speaks  of  a  surgeon  who  lost  two  cases  on  which  he  operated. 
Demarqnay  f  quotes  a  case,  reported  by  Marx,  where  a  passionate  and 
jealous  woman  made  her  lover  wear  a  gold  padlock  (sometimes 
two)  with  which  she  secured  the  preputial  orifice,  keeping  the  key 
herself.  The  victim  of  her  charms  carried  his  padlocks,  which  were 
replaced  from  time  to  time  through  new  punctures,  during  four  or  five 
years,  until  such  a  degree  of  irritation  had  been  set  up  that  Petroz 
and  Dui^uytren,  when  consulted,  diagnosticated  cancer,  and  removed 
the  prepuce.     No  relapse  of  the  "  cancer  "'  is  recorded. 

Inflammatory  Phimosis  is  a  transient  condition.  It  may  leave 
true  phimosis  behind,  as  above  detailed,  but  usually  does  not.  Any 
variety  of  phimosis  may  be  complicated  by  inflammation.  It  is  better 
not  to  circumcise  when  the  prepuce  is  inflamed,  if  it  can  be  avoided, 
as  the  process  of  repair  would  be  retarded,  and  an  ugly  cicatrix  may 
result.  If  the  inflammation  is  caused  by  chancroid,  this  rule  should 
be  particularly  observed  when  jiossible,  for  the  edges  of  the  wound 
become  inoculated  in  spite  of  every  precaution.  Where  inflammation 
is  slight,  but  cedema  excessive,  phimosis  ensues  (lymphitis).  Here 
position  and  pressure  with  collodion,  and  perhaps  puncture  on  each 
side  of  the  frajnum,  are  indicated,  or  light  cooling  lotions. 

Treatment  of  Injlammalory  PJdmosis. — Keep  the  patient  in  bed, 
and  elevate  the  penis  over  the  hypogastrium.  Evaporating  lotions 
may  be  used  locally,  containing  a  little  spirit  or  a  (gr.  x-xx)  solution 

*  "  Le  Progr6s  Med.,"  September  2,  1876.  f  Op-  «<•.  P-  392. 


MORBID   CONDITIONS   OF   THE   PIIEPUCE.  17 

of  tannin,  frequently  wasliing  out  the  cavity  of  the  prepuce  by  means 
of  a  syringe  with  a  Hat  nozzle,  with  some  mildly-stimulating  lotion, 
such  as  dilute  lead- water  or  carbolic  acid  (gr.  ij  to  the  ?  j),  or  Labar- 
raque's  solution  (  3  ss.  to  the  3  j). 

Eemote  Results  oe  Phimosis. — Besides  predisposing  to  local  in- 
flammatory disorders^  leading  to  imperfect  development  of  the  glans 
penis,  and  acting  as  an  obstacle  to  sexual  intercourse,  phimosis  may 
occasion  a  variety  of  morbid  conditions  by  reflex  action.  L'Allemand 
enumerates  it  among  the  causes  of  spermatorrhoea.  It  may  occasion 
frequent  desire  to  urinate  (irritability  of  the  bladder),  finally  cystitis  ; 
but  its  disturbing  influence  in  a  reflex  way  upon  the  rest  of  the  organ- 
ism I  believe  has  been  very  much  overrated. 

Dr.  Sayre,  of  New  York,  has  published  several  cases  of  relaxation 
of  the  muscles  of  the  back  with  curvature  of  the  spine  in  children, 
caused  by  phimosis  with  adhesions,  the  local  irritation  being  so  great 
as  to  keep  the  little  patient  in  a  condition  of  almost  constant  priapism. 
Prolapsus  ani  not  unfrequently  accomj)anies  phimosis  in  children  when 
the  prepuce  becomes  inflamed,  and  symptoms  resembling  those  of  stone 
in  the  bladder  are  not  uncommon  from  the  same  cause. 

Paraphimosis  (Trapa,  outside  ;  ^t/^ow,  /  bind)  exists  where  the  pre- 
puce gets  behind  the  corona  glandis  and  can  not  be  replaced. 

Causes. — An  unnaturally  tight  preputial  orifice  is  a  predisposing 
cause  to  paraphimosis.  It  sometimes  hapisens  that  young  boys,  who 
retract  the  prepuce,  perhaps  for  the  first  time,  find  themselves  unable 
to  replace  it.  Instances  are  reported  where  rings  of  metal  have  been 
forced  upon  the  penis,  retracting  the  prepuce.  The  glans  penis  now 
becoming  a  little  turgid,  the  patient  is  unable  to  remove  the  ring. 
Shame  deters  him  from  seeking  relief  at  once,  and  the  ring  is  only 
found  during  an  operation,  after  days  or  weeks  of  suffering,  buried 
deep  in  the  swollen,  oedematous,  perhaps  gangrenous  penis. 

Inflammatory  paraphimosis  may  depend  upon  balanitis,  gonorrhoea, 
herpes,  chancroid,  chancre,  etc.  The  prepuce,  already  a  little  in- 
flamed, is  retracted,  to  see  or  dress  some  ulceration  concealed  in  its 
cul-de-sac,  or  is,  perhaps,  held  back  by  bandage  for  convenience  of 
dressing,  or,  if  short,  becoming  inflamed  and  oedematous,  it  may  roll 
itself  back.  It  soon  inflames  further,  oedema  increases,  and  reduction 
becomes  impossible. 

Symptoms. — In  paraphimosis  the  glans  penis  is  swollen  and  livid. 
If  the  patient  is  seen  at  once,  there  may  be  no  inflammation,  either  of 
the  prepuce  or  the  glans  ;  but,  in  many  cases — in  all  eventually,  if  un- 
relieved— both  are  inflamed  to  a  greater  or  less  extent,  the  glans  per- 
haps being  gangrenous  from  arrest  of  circulation.  Behind  the  corona, 
most  marked  below,  rises  a  tense,  shining,  oedematous  belt  of  the  mu- 
cous layer  of  the  prepuce,  the  connective  tissue  of  which  is  filled  with 
serum.  Behind  this  there  is  a  deep  sulcus  or  furrow,  most  marked 
2 


18 


DISEASES   OF   THE   TEXIS. 


above,  often  the  seat  of  superficial  ulceration.  Here  lies  the  stricture  : 
behind  it  there  rises  another  aKJcmatous  fold,  usually  smaller  than  the 
one  in  front. 

If  the  stricture  of  the  prepuce  is  tight  enougli  to  arrest  the  circula- 
tion, it  may  linally  cause  the  destruction  by  gangrene  of  all  tissues 
lying  in  front  of  it. 

2'reatmint. — The  first  point  to  decide  in  a  case  of  paraphimosis  is 
in  regard  to  strangulation.  If  it  exist,  delay  is  inadmissible  ;  if  not, 
temporizing  exiiedieats  may  be  resorted  to,  to  reduce  inflammation, 
before  appealing  to  forcible  reduction  or  operation.  The  test  is  simple. 
In  strangulation  the  glans  penis  is  turgid,  swollen,  blue-black,  cold,  de- 
void of  sensibility,  and  perhaps  shows  already  points  of  commencing 
gangrene.  If  there  be  no  strangulation,  the  glans  may  be  normal,  or, 
if  swollen,  is  red — at  least  not  black — warm,  and  by  compression  the 
blood  may  be  driven  out  of  it  ;  sensibility  is  also  preserved.  A  para- 
phimosed  glans  penis  may  be  inflamed,  but  still  not  strangulated. 

Paeaphimosis  with  Strangulation. 
— In  these  cases  ether  should  always  be 
administered.  Often  under  the  relaxation 
of  anaesthesia  reduction  is  accomplished 
with  comparative  ease.  Ice  should  be  first 
used  locally  to  produce  shrinkage,  and  a 
few  small  jiunctures  may  be  made  to  let 
out  serum  from  the  ridge  in  front  of  the 
stricture,  if  the  swelling  be  excessive.  The 
following  are  the  best  methods  of  reduc- 
tion :  Seize  the  penis  behind  the  strictured 
prepuce  in  the  fork  of  the  index  and  mid- 
dle fingers  of  both  hands,  one  placed  on 
either  side.  This  gives  more  even  pressure 
forward  than  when  one  hand  only  is  used.  Now  make  pressure  with 
the  thumbs  on  both  sides,  in  such  a  direction  as  to  compress  the  glans 
laterally,  rather  than  from  before  backward,  and  at  the  same  time  pull 
the  strictured  portion  of  the  prepuce  forward,  the  idea  being  to  make 
the  glans  as  small  as  possible  by  compression,  and  rather  to  pull  the 
stricture  over  the  glans  than  to  push  the  glans  through  the  stricture. 
The  latter  attempt  is  liable  to  do  more  harm  than  good,  by  flattening 
out  the  glans  over  the  stricture,  and  rendering  redaction  less  possible 
than  before.  The  corona  and  a  little  of  the  mucous  layer  of  the  pre- 
puce beyond  should  be  slightly  oiled,  and  an  attempt  may  be  made  to 
insinuate  the  edge  of  the  thumb-nail  under  the  stricture  to  assist  in 
lifting  it  over  the  corona. 

In  some  cases  it  is  preferable  to  encircle  the  penis  with  one  hand, 
using  the  other  for  manipulation.  Finally,  Mercier's  method  might  be 
tried.     The  surgeon  stands  on  the  patient's  right,  places  the  index 


Fig.  4. 


MORBID   COiXDITIONS   OF   THE   PREPUCE. 


19 


and  middle  fingers  of  his  right  hand  longitudinally  along  the  lower  sur- 
face of  the  penis,  and  the  pulp  of  his  thumb  on  the  dorsum  of  the 
glans  penis  and  the  oodematous  ridge  in  front  of  the  point  of  stricture. 
By  firm  pressure  crowding  down  the 
swollen  mucous  layer  of  the  pre- 
puce, he  endeavors  to  insinuate  the 
end  of  the  thumb-nail  under  the 
stricture.  If  he  succeeds  in  this, 
grasping  the  penis  and  the  two  fin- 
gers of  the  right  hand  beneath  in  a 
circular  manner  with  the  left  hand, 
he  draws  the  strictured  point  up 
over  the  thumb-nail.  Bardinet's* 
method — inserting  the  rounded  end 
of  a  hair-pin  under  the  stricture  on 
each  side,  and  with  these  making 
lateral  pressure  upon  the  glans  while 
the  prepuce  is  worked  forward — is 
simple  and  often  effective. 

If  a  prolonged,  careful  attempt     .  Fio.^mmps). 

at  reduction  fails,  the  strictured  point  must  be  divided.  To  accom- 
plish this  subcutaneously,  a  tenotomy-knife  is  introduced  flatwise 
along  the  sheath  of  the  penis  under  the  stricture,  and  is  made  to  cut 

outward,  until  all  tension  is  re- 
lieved. Instead  of  this,  a  simple 
incision  may  be  made  through 
the  skin  down  to  the  sheath  of 
the  penis.  Inflammatory  con- 
solidation of  tissue  may  make  it 
necessary  to  divide  the  stricture 
at  several  points. 

After  reduction,  the  treat- 
ment consists  in  position,  rest, 
and  cleanliness,  syi'inging  the  preputial  cavity  with  warm  water  hold- 
ing a  small  amount  of  disinfectant,  or  mild  astringent,  in  solution. 
If  any  contagious  ulcer  has  been  the  cause  of  paraphimosis,  the 
surgeon  should  carefully  examine  his  fingers  for  cracks  or  fissures 
before  commencing  manipulation.  So  much  handling  is  required 
that  infection  is  very  apt  to  occur  unless  the  epidermis  of  the  hands 
is  sound. 

In  Paraphimosis  without  Stra]S"gulatiox,  if  the  case  is  recent, 
reduction  must  be  effected  or  inflammation  will  surely  set  in  and  com- 
plicate the  situation.  Eeduction  may  be  accomjilished  as  detailed 
above,  or  by  the  method  successfully  employed  in  the  Children's  Hos- 

*"L'Union  Medicale,"  ISIS,  p.  900. 


Fig.  6. 


20  DISEASES   OF   THE   TEXTS. 

pital  at  Pcstb.*  Here  the  penis,  j)rei)uce,  and  glans  arc  togctlier 
subjected  to  strong  continued  i)rcssure.  Several  narrow  strips  of 
adhesive  jilaster  are  applied  longitudinally  from  the  middle  of  the 
penis,  over  the  apex  of  the  glaus,  to  the  middle  of  the  penis  oppo- 
site the  starting-point.  The  meatus  urinarius  is  left  uncovered.  In  this 
way  the  organ  is  surroiinded  and  compressed  by  longitudinal  strips. 
Over  these,  commencing  just  behind  the  orifice  of  the  urethra,  a  nar- 
row strip  of  plaster  is  wound  spirally,  using  pretty  firm  pressure,  until 
the  penis  is  covered  by  its  circular  bandage  iip  to  the  middle.  The 
application  is  not  painful.  In  twenty-four  hours  reduction  may  be 
accomplished  ;  a  thin  rubber  bandage  is  more  simple  in  its  apjilica- 
tion,  and  more  pi-omptly  effective. 

In  old  or  anannic  patients,  having  gonorrhoea  or  an  ulcer  about  the 
head  of  the  penis,  accompanied  by  lymphangitis,  and  where  the  i)rcpuce 
is  short,  a  large  amount  of  serum  may  collect  in  the  prepuce,  roll  it 
back,  and  render  paraphimosis  imminent.  The  best  treatment  here  is  a 
little  rest,  with  elevation  of  the  penis  and  a])plication  of  a  twenty-grain 
solution  of  tannin,  followed  by  free  use  of  collodion  as  soon  as  the 
patient  rises.     Unlike  the  scrotum,  the  prepuce  bears  collodion  well. 

In  the  majority  of  cases,  when  complicating  chancroid,  herpetic,  or 
other  ulceration,  paraphimosis  is  purely  the  result  of  inflammation  and 
oedema,  and  there  is  no  strangulation.  Here  the  main  inflammatory 
condition  mxist  be  treated,  aided  by  position,  pressure,  puncture,  evai:)o- 
ratiug  and  astringent  lotions.  These  will  usually  be  sufficient,  but  in 
severe  cases  a  shar])  watch  should  be  kept  up  for  any  evidences  of  com- 
mencing strangulation.  Should  it  occur,  the  point  of  stricture  must  be 
straightway  relieved.  (For  other  diseases  of  the  prepuce,  posthitis, 
herpes,  Ycgetations,  cancer,  etc.,  refer  to  diseases  of  glans  penis.) 

DISEASES  OP  THE  GLANS  PENIS. 

Herpes  Progexitalis. — This  affection  consists  in  the  development 
of  clusters  of  vesicles  upon  reddened  patches  on  the  mucous  covering 
of  the  glans  or  on  either  layer  of  the  prepuce — occasionally  on  other 
])ortions  of  the  neighboring  skin — attended  by  a  slight  sensation  of 
heat  and  tingling.  When  occurring  on  the  cuticular  layer,  herpes 
runs  its  course  as  it  does  elsewhere  on  the  body  ;  but,  when  vesicles  de- 
velop "within  the  preputial  orifice,  the  eruption  is  modified.  Under 
these  circumstances  the  epithelium  of  the  vesicles  gets  soaked  off,  little 
exulcerations  result,  more  or  less  general  inflammation  is  apt  to  arise 
from  retention  of  the  secretions,  and  balanitis,  with  posthitis,  vegeta- 
tions, and  inflammatory  phimosis,  may  be  the  ultimate  result.  In 
broken-down  constitutions  the  ulcerations  perhaps  become  deep  and 
angry,  diagnosis  with  chancroid  difficult,  while  the  glands  in  one  or  both 
groins  may  inflame  and  suppurate.     These  extreme  results  are  rare. 

♦Schmidt's  "  Jabrbuclier,"  and  Bumstead  on  "  Venereal,"  p.  122,  1870. 


DISEASES   OF   THE   GLANS  PENIS.  21 

.  When  the  affection  has  once  occurred,  it  shows  a  marked  tendency 
to  return.  There  is  often  a  periodicity  about  the  attacks.  Tight  pre- 
puce and  contact  of  irritating  discharges  act  as  predisposing  causes. 

Diagnosis. — Vesicles,  usually  in  groups,  always  precede  the  ulcera- 
tions, while  the  latter  are  irregular  in  shape,  superficial,  and  very  rarely 
complicated  by  suppurating  bubo.  The  pus  is  not  auto-inoculable. 
Attention  to  these  points  will  generally  render  diagnosis  with  chancroid 
easy  ;  where  grave  doubts  exist,  auto-inoculation  is  the  proper  test. 

Treatment  is  the  same  as  for  balanitis.  In  relapsing  cases  a  long 
course  of  iron  and  arsenic  internally  often  effects  a  permanent  cure. 

Balanitis  {fSdXavo's,  a  gland)  is  an  inflammation  of  the  surface  of 
the  glans  penis.  Posthitis  (ttoo-Ot],  the  prepuce)  is  an  inflammation  of 
the  prepuce,  chiefly  affecting  its  internal  surface.  Neither  can  exist  for 
any  length  of  time  without  becoming  more  or  less  complicated  by  the 
other.     For  practical  purposes  they  must  be  considered  together. 

Causes. — Persons  of  irritable  skin  and  gouty  habit  are  predisposed 
to  this  disorder.  A  long  and  tight  prepuce  is  always  a  predisposing 
cause.  The  exciting  causes  are  mechanical  irritation  or  uncleanliness 
from  retention  of  smegma  preputii  (a  white,  curdy  substance  composed 
of  epithelial  cells  in  fatty  degeneration  and  sebaceous  matter),  or  from 
prolonged  contact  with  gonorrhoeal,  leucorrhoeal,  menstrual,  or  other 
irritating  fluids. 

Symptoms. — The  membrane  at  first  becomes  reddened,  then  mottled 
and  moist ;  next  the  epithelium  comes  off  in  patches,  leaving  irregular 
excoriations,  which  soon  ulcerate  and  discharge  a  purulent  fluid  of 
greater  or  less  consistence.  These  ulcerations  are  not  preceded  by 
vesicles.  There  is  a  burning  soreness  with  itching  at  the  end  of  the 
penis,  usually  scalding  on  urination.  The  whole  substance  of  the  pre- 
puce may  inflame,  become  intensely  reddened  around  the  orifice,  and 
infiltrated  with  serum,  producing  inflammatory  phimosis,  especially  if 
the  prepuce  is  naturally  long  or  tight.  The  ulcerations  rarely  become 
deep,  and  the  inguinal  glands  do  not  often  suppurate.  They  frequently 
become  somewhat  large  and  tender.  In  chronic  balanitis  with  phimosis, 
the  mucous  surface  of  the  prepuce  is  found  upon  exposure  to  be  covered 
with  granular  prominences.     Warty  growths  are  not  infrequent. 

K.  W.  Taylor^  has  described  a  peculiar  ringed  affection  of  the  pre- 
puce and  glans — narrow  rings  of  reddened  mucous  membrane  covered 
by  a  thin  layer  of  eijithelial  scales.  The  inclosed  area  is  normal,  the 
rings  vary  from  one-fourth  to  one-half  inch  in  diameter.  Sometimes 
there  are  segments  of  circles.  The  affection  is  sometimes  painful  or 
itching.  The  rings  remain  stationary  for  a  time.  Sometimes  they 
come  out  in  successive  crops.  They  get  well  withoiit  scar,  slowly, 
under  the  use  of  arsenic  internally.  They  should  not  be  confounded 
with  lichen  planus  of  the  glans  penis. 

*  "Archives  of  Medicine,"  vol.  xii,  No.  3,  December,  1834. 


22  DISEASES   OF   THE   PENIS. 

Diagnosis. — Balanitis  may  be  confoimdcd  with  herpes,  ehaueroicl, 
chancre,  or  gonorrluoa.  x\t  the  ulcerative  stage  it  can  not  be  distin- 
guished from  balanitis  supervening  upon  herpes.  In  the  early  stage 
its  vesicular  origin  distingnishes  it.  Chancre  is  usually  single  and  in- 
durated. In  chancroid  the  ulcerations  are  deeper  and  the  pus  auto- 
inoculable,  yet  both  of  these  specific  ulcers  may  be  com})licated  by 
balanitis.  Balanitis  has  been  described  under  the  name  of  external 
gonorrhoBa.  It  may  be  mistaken  for  actual  gonorrhoea,  if  there  is 
phimosis,  under  which  circumstance  it  is  very  a])t  to  complicate  the 
main  mahuly.  AVhen  the  meatus  urinarius  can  be  seen,  however,  a 
little  care  will  easily  decide  whether  the  pus  comes  from  the  urethra 
or  not. 

Treatment. — If  the  prepuce  can  be  retracted,  simple  balanitis  may 
be  speedily  relieved.  Cleanliness  is  of  the  first  importance,  but  soap 
should  not  be  used.  Warm  water  with  the  disinfectant,  if  needed, 
will  remove  all  the  discharges.  After  washing,  the  parts  should  be 
dried  by  gently  touching  them  with  a  soft  cloth,  and  dusted  with  a 
mixture  of  finely  powdered  calomel  and  calcined  magnesia,  or  with 
calomel  alone.  If  the  ulcerations  are  deep,  iodoform  is  preferable. 
A  piece  of  lint  or  old  linen,  cut  so  as  to  be  just  large  enough  to  cover 
the  surface  of  the  glans,  is  now  to  be  moistened  in  one  of  the  follow- 
ing lotions  : 


Or, 

Or, 
Or, 


5  Vin.  aroiual.,  3  ij- 1  ss. 

Aquae,  |  j. 

5  Pulv.  opii,  3  j- 

Dissolve  in  six  ounces  of  boiling  water,  and  add 
Liq.  plumbi  subacetat.,  3  j- 

Filter  and  cool. 

IJ  Aluminis  exust.,  gr.  v-x. 

Aquie,  3  j. 

Simple  dilute  lead-water,  or  a  gr.  ij-iv  solution  of  sulphate  of  zinc. 


The  linen  so  moistened  is  laid  around  the  glans,  leaving  the  apex 
and  meatus  uncovered  ;  and,  finally,  the  prepuce  is  pulled  forward  to 
its  natural  position.  In  this  way  friction  between  the  inflamed  sur- 
faces is  avoided,  all  the  discharges  are  absorbed,  and  a  mildly  stimu- 
lating fluid  is  kept  in  constant  contact  with  the  ulcerated  or  abraded 
surfaces.  The  dressing  should  be  repeated  twice  to  four  times  daily, 
according  to  the  discharge.  iVfter  recovery  a  dry  piece  of  linen 
should  be  kept  between  the  glans  and  preijuce  for  some  weeks,  re- 
newed twice  daily. 

If  the  prepuce  can  not  be  retracted,  its  cul-de-sac  should  be  thor- 
oughly washed  out  with  tepid  water,  by  means  of  a  syringe  with  a  flat 
nozzle,  if  possible,  every  two  or  three  hours,  according  to  the  rapidity 


DISEASES   OF   THE   GLANS   PENIS.  23 

of  the  formation  of  the  pus  ;  iind,  each  time  after  the  cavity  has  been 
cleaned,  a  mild  solution  of  carbolic  acid,  or  enough  of  any  of  the 
lotions  above  mentioned,  to  distend  the  prepuce,  should  be  gently 
thrown  in,  retained  a  moment,  and  then  allowed  to  escape. 

If  the  prepuce  is  much  inflamed,  rest,  position,  and  evaporating 
lotions  locally,  should  be  used  in  addition  to  the  other  measures.  If 
the  inflammation  runs  so  high  that  sloughing  of  the  prepuce  seems  im- 
minent, it  is  better  to  take  off  the  tension  by  slitting  up  the  dorsum. 
If  chancroid  be  present,  however,  the  surgeon  must  remember  that 
inoculation  of  his  wound  is  inevitable.  The  diagnosis  of  chancroid 
can  be  made  by  auto-inoculation  of  the  pus.  If  this  gives  a  positive 
result,  it  sometimes  becomes  a  matter  of  the  nicest  judgment  to  decide 
whether  to  operate  or  not.  In  cases  of  grave  doubt,  it  is  best  to  ojier- 
ate  in  order  to  expose  the  sore,  whose  ravages  (perhaps  of  the  glans 
penis)  are  going  on  in  darkness  uncontrolled.  A  large  chancroid  ex- 
posed is  better  than  a  smaller  one  concealed. 

In  chronic  and  inveterate  cases  of  balanitis,  or  where  insignificant 
causes  produce  constant  relapse,  circumcision  affords  a  certain  cure. 
All  the  unhealthy,  thickened,  inner  layer  of  the  prepuce  should  be 
removed.  Where  this  is  seriously  objected  to,  which  is  rarely  the  case 
when  there  is  much  suffering,  relapses  may  be  rendered  less  frequent 
by  the  observance  of  the  strictest  cleanliness,  and  the  use  of  a  filtered 
solution  of  tannin  and  acetate  of  lead,  or  of  tannic  acid  in  glycerin, 
3  J  to  I  j  ;  or  of  alcohol,  one  part  to  two  of  water,  kept  up  for  a  long 
time,  followed  by  long  use  of  a  piece  of  dry  linen  to  separate  the  m.u- 
cous  surfaces. 

Adhesions  after  balanitis  are  uncommon  after  the  age  of  early 
childhood. 

Vegetatio^sts  upon  the  penis  are  commonly  denominated  venereal 
loarts.  This  title,  however,  is  not  exact,  since  there  is  no  necessary 
connection  between  them  and  any  venereal  disease  as  a  cause.  They 
are  nothing  more  nor  less  than  papillary  overgrowths,  often  highly 
vascular,  and  composed  in  large  excess  of  epithelium.  They  may  be 
prominent  and  pedunculated,  or  flat,  and  growing  from  a  considera- 
able  surface.  They  are  nearly  always  multi23le.  They  are  caused  by 
the  contact  of  irritating  fluids  with  a  membrane  of  naturally  delicate 
texture,  or  simply  by  lack  of  cleanliness.  The  most  favorable  condi- 
tion for  their  production  consequently  exists  in  gonorrhoea,  balanitis, 
or  when  mucous  patches  occupy  the  cavity  of  the  prepuce.  Their 
favorite  seat  is  just  behind  the  corona  glandis,  but  they  are  also  en- 
countered anywhere  within  the  cavity  of  the  prepuce — at  its  orifice, 
upon  its  cutaneous  surface — or  even  within  the  urethra.  They  are 
found  also  upon  the  scrotum,  and  frequently  around  the  anus.  They 
are,  when  numerous,  bathed  in  a  fetid,  puriform  secretion,  and  may 
get  large  enough  within  the  prepuce  to  cause  phimosis.     They  occur 


24  DISEASES  OF   THE   PEXIS. 

upon  young  childron,  and  are  found  in  tlioir  greatest  luxuriance  with- 
in and  around  the  vulva  of  pregnant  women  attected  with  irritating 
discharges — discharges  by  no  means  of  necessity  venereal  in  any  sense. 
There  is  a  contagious  element  about  them. 

Treatment. — The  observance  of  cleanliness  alone  often  causes  vege- 
tations to  shrink  up  and  disappear.  In  any  case  this  is  the  first  essen- 
tial to  the  success  of  any  course.  In  case  vegetations  are  complicated 
by  balanitis,  treatment  of  the  latter  will  often  at  the  same  time  triumph 
over  the  warts.  If  they  persist,  however,  or  constitute  the  main  dis- 
ease, all  the  pedunculated  growths  should  be  carefully  removed  with 
curved  scissors,  and  the  surface  from  which  they  grow  cauterized  with 
nitric  acid  or  any  other  escharotic.  The  flat  growths  are  best  disposed 
of  by  the  ap])lication  of  nitric  acid,  at  intervals,  until  the  base  from 
which  they  spring  has  been  destroyed.  If  the  warts  are  dry,  they  may 
be  covered  sejjarately  with  collodion  containing  corrosive  sublimate, 
in  the  proportion  of  3  j  to  33.  This  is  allowed  to  dry  on,  and,  when 
it  separates,  all  or  the  greater  part  of  the  wart  comes  with  it.  The 
application  may  be  repeated  if  necessary.  Where  the  number  of  vege- 
tations is  too  great  to  allow  of  their  treatment  seriatim,  attention  to 
the  general  health,  cleanliness,  and  local  dusting  with  calomel  is  the 
proper  course.  This  plan,  so  efficacious  in  treating  condylomata  and 
mucous  patches  about  the  anus,  is  particularly  applicable  where  the 
vegetations  are  surrounded  by  an  excess  of  moisture. 

Epithelioma  Penis. — The  epithelial  variety  of  cancer  is  that  form 
which  usually  attacks  the  glaus  penis  and  the  prepuce.  It  commences 
more  frequently  upon  the  former — generally  after  middle  life. 

Symptoms. — Epithelioma  usually  first  appears  as  a  small,  flat, 
warty,  or  simply  excoriated  surface,  of  which  the  base  is  perhaps  from 
the  first  slightly  indurated,  especially  when  the  disease  commences  at 
the  meatus.  The  surface  of  this  insignificant  induration  becomes  ex- 
coriated, bleeds  a  little,  and  is  the  seat  of  a  slight  darting  or  burning 
pam.  A  dark-colored  scab  now  forms  if  the  spot  is  exposed  to  the 
air,  but  this  is  picked  off  or  falls  off,  disclosing  an  ulcerated  surface 
beneath.  In  this  way  the  disease  advances  by  ulceration  backward, 
involving  everything  in  its  course.  The  discharge  is  thin,  sanious, 
fetid  ;  the  ulcer  deep,  irregular,  unhealthy  ;  the  edges  hard,  sinuous, 
livid,  everted.  Its  course,  at  first  slow,  becomes  later  more  rapid,  pur- 
suing the  usual  march  of  epithelial  cancer  in  other  localities.  In  some 
cases  the  wart-growth  becomes  exuberant  before  ulceration  occurs. 

As  the  disease  advances  the  patient  fails  in  strength.  The  inguinal 
glands  on  both  sides  become  involved  and  may  ulcerate.  Now,  if  the 
strength  hold  out,  the  disease  will  spread  from  the  root  of  the  penis 
over  the  abdomen,  groins,  thighs,  and  perinreum,  and  involve  the  anus. 
The  scrotum  may  ulcerate  awa)%  leaving  the  testicles  hanging  out,  and 
in  this  horrid  condition  the  sufferer  dies,  worn  out,  or  perhaps  sudden- 


DISEASES   OF   THE   CORPORA   CAVERNOSA.  25 

]y  from  hgemorrhago,  some  large  vessel  in  tlic  perinaeum  being  opened 
by  the  advancing  ulceration. 

The  diagnosis  of  epithelioma  of  the  penis  is  often  difficult  in  tJio 
early  stages.  All  warty  growths,  especially  if  they  are  not  much  ele- 
vated and  occur  upon  individuals  past  middle  life,  whose  habits  seem 
to  be  cleanly,  and  above  all  if  there  is  even  a  shade  of  hardness  around 
the  base  of  the  growth,  all  such  excrescences  should  be  regarded  with 
suspicion,  and  their  progress  carefully  watched.  When  ulceration  com- 
mences, doubt  may  be  laid  aside,  and  then  temporizing  is  of  no  avail. 
Active  measures  should  be  resorted  to  at  once,  unless  the  age  of  the 
patient  or  some  other  condition  contraindicates  an  operation. 

Prognosis  and  Treatment. — Vigorous  measures  before  the  inguinal 
glands  become  involved  afford  the  only  chance  of  cure,  and  even  then 
prognosis  must  be  guarded,  for  relapse  locally  or  in  the  glands  is  very 
common.  Extensive  local  scraping  and  cauterization,  if  applied  very 
early,  may  cure  a  superficial  case  ;  but  deep  ulceration  imperatively  de- 
mands amputation  at  a  point  by  so  much  the  farther  back  as  the  ulcera- 
tion is  extensive.  It  is  mistaken  kindness  to  spare  tissue  in  such  cases. 
If  the  inguinal  glands  are  involved,  they  also  should  be  thoroughly  re- 
moved at  the  same  sitting  ;  but  even  such  removal  affords  little  hope 
of  permanent  cure.  In  old  cases  of  extensive  disease,  the  bladder 
should  be  permanently  drained  above  the  pubes  or  through  the  peri- 
naeum for  the  patient's  comfort,  and  anodynes  used  freely. 

DISEASES  OF  THE  COEPOEA  CAVERNOSA. 

Injuries  of  corpora  cavernosa  and  cancer  have  been  already  de- 
scribed. 

Inflammation  of  the  substance  of  the  corpora  cavernosa  is  very 
rare,  except  as  the  result  of  contusion,  when  it  may  run  high,  become 
excessively  painful,  and  terminate  in  suppuration  or  gangrene.  Spon- 
taneous inflammation  occurs,  very  exceptionally,  during  the  course  of 
acute  dyscrasial  disease — typhus,  small-pox,  etc.  It  may  complicate 
severe  urethritis.  It  is  always  a  dangerous  affection,  tending  to  termi- 
nate in  gangrene. 

Treatment. — Beyond  sustaining  strength,  but  little  can  be  done. 
Evaporating  lotions  may  he  used  locally.  If  pus  forms,  it  should  be 
evacuated  early,  using  care  to  distinguish  between  pus  and  effused  blood. 

Ossification  of  the  Penis  is  excessively  rare.  J.  von  Lenhossek  * 
found  what  he  helieves  to  be  the  first  case  observed,  in  an  autopsy  upoi 
a  patient  of  forty-two,  dead  of  typhus.  There  were  dorsal  and  ventral 
bones,  with  channels  for  the  vessels  and  the  urethra.  The  point  of 
origin  seemed  to  be  the  septum  of  the  corpora  cavernosa.  Haversian 
canals  and  true  bone  corpuscles  were  found.  Demarquay  f  figures  a 
specimen  representing  a  large  bone  in  the  center  of  the  penis  reaching 

*  Virchow's  "  Archiv.,"  Ix,  April,  1874,  p.  1.         f  Op.  cit,  354. 


26  DISEASES   OF   THE   TEXIS. 

from  the  glans  half  way  back,  taken  from  the  Vienna  Pathological 
Museum,  s})eoimen  2,3-i2.  Wm.  II.  Porter*  reports  a  case  of  true 
osteoma  of  the  penis. 

Calcification  of  the  Pexis. — Ossification  was  the  term  formerly 
ajiplied  to  this  affection  until  the  niicroscoiie  demonstrated  the  absence 
of  bone  corpuscles  in  the  earthy  mass.  Calcification  consists  in  a  depo- 
sition of  plates  of  calcareous  matter  in  the  corpora  cavernosa,  one 
or  both,  particularly  in  the  fibrous  sheath.  The  condition  is  analo- 
gous to  atheroma  of  arteries.  Mild  chronic  inflammation,  followed  by 
fatty  degeneration,  precedes  the  calcareous  deposit.  The  disease  usu- 
ally comes  on  insidiously,  and  discloses  itself  by  the  fact  that  erection 
is  imperfect  and  painful.  The  penis  bends  during  erection,  the  calca- 
reous jiatch  occupying  the  center  of  the  concavity  of  the  curve,  since 
the  sheath  loses  its  elasticity  at  this  point,  and  whatever  of  the  erectile 
tissue  is  involved  is,  of  course,  indistensible. 

Tlie  causes  of  calcification  of  the  penis  are  unknown,  f  Injury  has 
no  ]30wer  to  produce  it.  It  occurs  after  middle  life,  when  all  calcifi- 
cations are  most  common. 

Prognosis. — The  calcification  may  cease  after  more  or  less  of  each 
corpus  cavernosum  has  suffered,  or  it  may  involve  the  whole  organ 
pretty  generall}'.  The  hard  plates  and  masses  of  calcareous  matter  can 
be  distinctly  felt  on  manipulation.  Sexual  intercourse  is  liable,  finally, 
to  be  seriously  interfered  with,  if  not  jireveuted  altogether.  Under 
these  circumstances  the  patient  is  often  driven  to  thoughts  of  suicide, 
urged  on  by  that  morbid  depression  which  always,  in  the  male,  accom- 
panies a  consciousness  of  sexual  iucajiacity,  be  that  incapacity  fancied 
or  real. 

Treatment. — Medicine  holds  out  no  hope  to  the  sufferer.  If  the 
disease  has  come  to  a  stand-still  and  the  deposit  is  superficial  and 
small,  it  may  be  removed  with  the  knife — an  oj^eration  which  has  been 
performed  with  success  by  Eegnoli  and  by  MacClellan.J 

Chroxic  Circumscribed  Inflammation  of  the  erectile  tissue  of 
the  corpora  cavernosa.  This  very  rare  malady  was  described  in  the 
first  edition  of  this  treatise  upon  a  foundation  of  five  typical  cases 
which  I  had  seen  with  Dr.  Van  Buren,  and  which  were  there  detailed. 
Since  that  time  I  have  seen  about  a  dozen  new  cases,  but  I  have  learned 
no  new  feature  of  the  disease.  I  have  seen  only  one  case  become  entire- 
ly well.  But  I  have  encountered  a  number  of  cases,  scattered  through 
the  literature  of  the  day,  and  shall  note  the  opinions  of  others  on  this 
peculiar  malady  while  I  adhere  to  the  original  description  of  its  2)hysi- 
cal  characters  and  course,  as  given  in  the  first  edition. 

The  affection  comes  on  insidiously,  without  apparent   cause,  al- 

*  "New  York  Medical  Record,"  September  2,  1882,  p.  270. 

\  Cretification  of  products  of  inflammation  is  not  here  referred  to. 

X  Velpeau,  "  Xouveaiix  Elements  de  Medccine  Operatoire,"  Paris,  1839,  vol.  iv,  p.  33G. 


DISEASES   OF   THE   CORPORA   CAVERNOSA.  27 

though  the  patient  sometimes  ascribes  it  to  local  injury.  He  first  dis- 
covers that  something  is  wrong  by  noticing  a  slight  pain  in  the  penis 
at  a  certain  point  when  the  organ  is  erect.  On  examination  he  detects 
a  hard,  flattened  mass,  with  sharj)ly-defined  margins,  occupying  tljo 
substance  of  one  or  both  corpora  cavernosa  near  the  surface,  and  feel- 
ing like  cartilage — elastic,  springy  ;  not  with  a  bony  feel  like  a  calca- 
reous plate.  The  corpus  spongiosum  never  ^participates  in  the  disease. 
The  penis  bends  during  erection  at  the  affected  point,  and  along  the 
edge  of  the  hardness  a  little  pain  is  experienced.  This  indurated  mass, 
which  is  of  varying  size  and  usually  irregularly  oval  in  shape,  with 
often  a  projecting  line  of  hardness  toward  the  root  of  the  ^lenis,  may 
remain  stationary  for  an  indefinite  period,  gradually  decreasing  at  last 
without  moving,  or  progress  slowly  backward  or  forward,  sometimes 
retaining  its  size  and  shape  by  disappearing  anteriorly  as  it  advances 
toward  the  root  of  the  penis,  or  vice  versa,  sometimes  growing  larger 
by  remaining  stationary  at  one  end  while  it  enlarges  at  the  other,  or 
by  growing  laterally.  A  slight  tenderness  is  sometimes  felt  along  the 
line  of  advancing  induration,  and  moderate  uneasiness  is  usually  pro- 
duced by  pressing  the  induration  between  the  fingers,  the  same  feeling 
as  that  experienced  during  erection.  The  seat  of  election  is  the  dor- 
sum of  the  penis  forward,  the  patch  spreading  equally  around  each 
corpus  cavernosum,  and  being  usually  more  blunt  forward  than  pos- 
teriorly. Sometimes  a  single  patch  is  found  laterally  in  one  corpus 
cavernosum,  not  reaching  the  dorsum,  and  there  being  no  companion 
on  the  other  side.  The  disease  occurs  after  middle  life.  The  patients 
are  usually  healthy,  and  certainly  are  not  uniformly  subject  to  any 
diathetic  disease,  although  more  patients  are  noticed  as  having  had 
gout  or  rheumatism  than  any  other  malady.  Gronorrhoea,  syphilis, 
stricture,  bear  no  possible  etiological  relation  to  this  malady,  and  treat- 
ment by  mercury  and  iodide  of  potassium  is  absolutely  negative.  The 
integument  of  the  penis  is  in  no  way  involved.  The  malady  appears 
to  be  a  chronic  thickening  of  the  sheath  and  a  portion  of  the  under- 
lying erectile  tissue  of  the  corpus  cavernosum,  which  thickening  aj)- 
pears  to  obliterate  the  meshes  of  the  erectile  tissue  and  prevent  their 
distention  with  blood  during  erection  of  the  rest  of  the  organ.* 

This  malady  appears  to  have  been  observed  and  described  by  De 
Lapeyronie,f  but  first  accurately  depicted  by  Kirby,J  who  gave  some 

*  Syphilitic  gummata  of  the  corpora  cavernosa  have  physical  characters  similar  to 
those  above  detailed,  except  that  the  syphilitic  node  is  more  deep  (sometimes)  and  often 
less  sharply  defined  than  the  malady  above  considered,  and  the  node  breaks  down  or  in- 
creases in  all  directions — or  perhaps  resolves — but  it  does  not  increase  on  one  side  while 
it  gets  well  on  the  other.  Furthermore,  gummy  tumor  is  dissipated  by  treatment.  Ricord 
has  given  a  description  of  these  gummata  in  the  corpus  cavernosum.  Zeissl  believes  that 
they  almost  always  occur  in  the  posterior  third  of  the  organ. 

f  "  Mem.  de  I'Acad.  de  Chir.,"  1*743,  tome  i,  p.  423. 

X  "Dublin  Medical  Press,"  1849,  vol.  xxii,  p.  210. 


28  DISEASES   OF   THE   TEN'IS. 

cases,  and  came  to  the  conclii.sion  that  gout  was  the  efTicient  cause. 
Actou,  in  his  ''  Koprocluctive  Organs,"  refers  vaguely  to  two  cases  of 
imperfect  erection  as  "strange  anomalies."  Possibly  these  two  cases 
were  examples  of  the  malady  under  consideration.  II.  J.  Johnson* 
reports  four  cases  as  "  chronic  inllammation  of  the  corpora  cavernosa."' 
Galligo  f  describes  these  indurations  as  special  tumors  of  the  jienis,  in 
1852.  Demar(piay  \  refers  to  this  malady  as  having  been  described 
under  tiie  names  induration  of  the  erectile  tissue  of  the  penis,  nodes, 
ganglions  of  tiie  corpora  cavernosa,  plastic  induration,  by  many  au- 
thors— Boyer,  Patissier,  Lcrminier,  Vidal  (De  Cassis),  Eicord,  and 
others.  Cruveilhier  *  believes  the  affection  to  be  a  fibrous  transforma- 
tion of  the  erectile  tissues  of  the  penis,  but  doubtless  some  of  the 
authors  above  named  have  confused  the  results  of  fracture  and  trau- 
matisms, gummata,  tumors,  and  calcifications  with  the  malady  now 
under  consideration.  Gross,  in  his  "Surgery"  (1859),  mentions  an 
indurated  tumor  of  the  pectiniform  septum,  removed  by  operation, 
which  may  have  been  some  analogous  condition.  Marchal  (De  Calvi)  || 
gives  a  case  occurring  in  a  diabetic  subject.  Prescott  Hewett  ^  reports 
two  cases  in  1866,  calling  the  malady  a  spontaneous  blocking  of  the 
corpus  cavernosum,  and  ascribing  it  to  gout  as  a  cause.  J.  Mason 
Warren,^  in  18G7,  gives  three  cases  of  apparently  typical  examples  of 
this  malady  under  the  name  of  indurated  tumor  of  the  penis.  He 
notes  one  case  where  the  induration  completely  disappeared.  Charles 
G.  Smith,  of  Fall  River,!  reported  a  case  in  1874,  and  in  tlie  same 
year  Howard  Marsh,!  of  St.  Bartholomew's,  brought  out  three  cases. 
Eldridge  %  gives  a  case  in  1876.  I  have  not  attempted  to  put  into 
print  a  dozen  or  more  cases  which  I  have  encountered  since  the  first 
edition  of  this  treatise  appeared,  most  of  which  were  seen  as  private 
patients  in  my  office,  and  a  few  presented  at  the  Xew  York  Dermato- 
logical  Society  by  several  of  its  members.  Hodgen,**  of  St.  Louis,  re- 
ported three  cases  in  1876  as  "reflex  induration  of  the  jienis."  He 
thought  that  the  influence  of  cold  had  a  causal  relation  to  his  cases. 
Cameron  (Mcdico-Chirurgical  Society  of  Glasgow,  October  8,  1879) 
read  an  essay  on  gouty  tumors  of  the  penis,  reproducing  Kirby's  ideas 
as  to  the  cause  of  these  formations.     Sir  James  Paget  advocates  the 

*  London  "  Lancet",  November,  1851,  p.  481. 

f  "Gaz.  Medicale,"  1852,  p.  440  (reference  from  "  Gaz.  Med.  Italiana  Toscana  "). 
X  Op.  ciL,  p.  344. 

*  "  Anatomie  Pathologi(iuc,"  tome  iii,  p.  594. 
II  "Les  Accidents  Diabetifiues,"  1864,  p.  401. 

^  "St.  Bartholomew's  Hospital  Reports,"  18(56,  vol.  ii,  p.  82,  et  scq. 

()  "Surgical  Observations  with  Cases,"  Boston,  18G7,  p.  245. 

I  "New  York  Medical  Journal,"  June,  1874,  p.  OOC. 

I  "  New  York  Medical  Journal,"  Sept.,  1874,  p.  269. 

I  "New  York  Medical  Journal,"  1876,  p.  260. 

**  "  Transactions  of  the  Medical  Association  of  the  State  of  Missouri,"  1876,  p.  28. 


DISEASES   OF   THE   COlirORA   CAVEKNOHA.  29 

same  etiology.  Finally,  Verncuil,*  in  1883,  reports  four  cascH,  in  whicli 
glycosuria  coincided  in  three.  He  believes  tlie  condition  to  be  non- 
inflammatory, and  analogous  to  the  contractions  of  the  palmar  and 
plantar  aponeurosis  which  are  encountered  among  gouty  subjects.  lie 
thinks  the  cause  is  gouty,  and  is  interested  in  tiie  fact  that  three  out 
of  four  were  also  diabetic.  Trelut,  in  the  same  meeting  of  the  surgi- 
cal society,  reported  that  he  had  seen  two  cases,  Monod  one,  and  Le 
Fort  three,  none  diabetic.  I  do  not  know  that  the  urine  was  tested 
for  sugar  in  the  earlier  cases  seen  by  Dr.  Van  Buren  and  myself. 
None  of  the  later  cases  examined  were  diabetic,  or  any  of  them,  so  far 
as  I  know.  Some  of  the  cases  had  the  gouty  diathesis,  but  this  can 
not  be  affirmed  of  all  of  them.  Tuffier,f  in  an  exhaustive  article, 
while  omitting  a  number  of  cases  of  which  I  have  record,  has  collated 
thirty-five  cases,  in  which  no  diathesis  is  noted  in  nine,  fifteen  were 
gouty,  and  eleven  diabetic.  The  malady  being  far  more  common  in 
advanced  life  than  at  any  other  time,  he  searched  patiently  among 
twenty-five  hundred  old  men  at  Bicetre  and  at  Ivry  without  finding  a 
single  specimen  of  which  to  study  the  pathological  anatomy  after  cut- 
ting it  out,  and  mentions  Cruveilhier  and  Eicord  as  having  been  equally 
unsuccessful  in  trying  to  find  a  case  for  dissection  ;  but,  after  his  arti- 
cle was  finished,  one  of  these  nodosities  was  cut  out  by  Verneuil,  Oc- 
tober 25,  1884,  and  Leloir  reported  that  in  its  pathological  histology  it 
was  composed  of  a  tissue  analogous  to  that  of  keloids — embryonic  cells 
m  clusters  tending  to  fibrous  transformation,  few  vessels,  with  fibrous 
planes  resembling  cicatricial  tissue. 

Prognosis. — The  prognosis  is  negatively  good  in  that  the  malady 
never  ulcerates  or  degenerates  into  anything  malignant,  may  get  spon- 
taneously better,  even  possibly  well,  or  may,  and  sometimes  does, 
progress  backward  until  it  gets  so  low  down  toward  the  root  of  the 
penis  that  it  no  longer  interferes  seriously  with  upright  erection.  I 
have  seen  more  than  one  patient  who,  at  one  time  being  debarred  from 
sexual  intercourse,  has  by  a  shifting  of  the  position  of  the  induration 
again  become  capable.  In  one  case  I  believe  this  was  due  to  an  im- 
provement in  the  condition  of  the  induration  without  any  change  in 
its  position — a  change  coming  on  spontaneously. 

Treatment. — An  effective  treatment  of  this  singular  malady  is  yet 
to  be  discovered.  Thus  far  only  time  has  seemed  to  help  it,  while 
blisters,  oleate  of  mercury,  tincture  of  iodine  externally,  with  mercury, 
the  iodides  of  potassium,  and  sodium,  and  local  electrolysis,  have  uni- 
formly failed.  Perhaps  alkaline  or  anti-gouty  remedies  may  hare 
something  more  to  offer  in  the  future  than  the  ineffective  means  now 
in  use. 

*  "  Bull,  de  la  Soc.  de  Chir.,"  1883,  tome  viii,  p.  826. 

f  "Ann.  des  Mai.  des  Org.  Genito-Uriuaires,"  July  and  August,  1885. 


30  DISEASES   OF   THE   URETHRA. 


CHAPTER    II. 
DISEASES    OF    TUB  URETHRA. 

Anatomy.— Natural  Curve  of  the  iTcthra.— Propor  Curve  for  Instruments.— Catheterism;  Obstaclee 
to  Catheterii-ni  in  the  llealtliy  Urethra.— Deformities  of  the  Urethra  ;  Imperforation,  Atresia, 
Hypospadias,  Ilorniaphroilisni,  Epispadias. — Urethral  and  Sexual  llygiene. — Injuries  of  the 
Urethra.— I'rethral  Fever. — Foreign  Bodies. — Polyi)i. 

TuE  urctlira  is  alwa3-s  a  shut  canal  througliout  its  whole  course, 
except  ■when  distended  by  some  foreign  substance.  Commencing  at 
the  neck  of  the  bladder,  it  tunnels  the  u])per  part  of  the  prostate, 
perforates  the  triangular  ligament,  and  terminates  at  the  end  of  the 
penis.  Its  size  varies  greatly,  and,  like  the  penis  and  testicles,  it  re- 
mains comparatively  very  small  until  after  puberty.  Its  length  has  been 
estimated  at  all  points  between  five  and  fourteen  (Pitha)  inches.  The 
length  varies  with  the  condition  of  erection  or  flaccidity  of  the  organ. 
Its  mucous  membrane,  according  to  Robin  and  Cadiat,*  is  manifest- 
ly richer  in  elastic  fibers  than  any  mucous  membrane  of  the  body. 
It  may  be  lengthened  by  disease  (enlarged  prostate).  In  round  num- 
bers, the  length  of  the  urethra  of  a  well-proportioned  adult  is  eight 
inches,  six  lying  in  front  of  the  triangular  ligament  (spongy  portion), 
a  little  less  than  one  inch  between  this  and  the  apex  of  the  prostate 
(muscular  or  membranous  portion),  a  little  more  than  one  inch  sur- 
rounded by  the  prostate  (prostatic  portion). 

The  sjiongy portion  is  surrounded  throughout  by  the  erectile  corpus 
spongiosum,  terminating  below  in  the  bulb.  Here  the  canal  pierces 
the  triangular  ligament — that  firm,  fibrous  fascia,  stretching  across  the 
space  bounded  by  the  ischio-pubic  rami — and,  becoming  membranous, 
is  covered  (besides  the  muscular  fibers  of  organic  life)  by  voluntary 
muscular  tissue  which  entirely  surrounds  it.  This  muscle  has  had 
special  names  given  to  different  portions  of  it  by  Guthrie,  iliiller,  and 
Wilson.  In  this  muscular  group,  described  as  one  muscle  by  Cruveil- 
hier  (transverso-urethral),  is  often  the  seat  of  spasmodic  stricture  ; 
and  it  is  here  that  muscular  contraction  may  oppose  the  passage  of  an 
instrument  into  the  bladder  for  several  minutes,  even  when  there  is 
no  evidence  of  urethral  disease.  These  are  the  muscles  which  consti- 
tute the  voluntary  "  cut-ofP,"  over  which  every  healthy  individual  has 
full  control.  To  allow  the  urine  to  pass,  these  are  voluntarily  relaxed, 
with  the  vesical  sphincter,  and  then  the  detrusor  expels  the  urine  by 
its  tonic  tendency  to  contraction,  over  which  the  individual  has  no 

*  "  Structure  intime  dc  la  muqueuse  et  des  glandes  urcthrales,"  "Journ.  dc  I'Anat.  ct  dc 
la  Physiologic,"  September,  1874,  p.  514. 


THE   UIIETIIRA.  31 

control.  If  a  catheter  be  introduced,  so  us  to  do  away  with  any  effect 
of  the  ''cut-off"  muscles,  no  voluntary  effort  of  the  individual  can 
arrest  the  stream  of  urine,  nor  indeed  cause  it  to  flow  with  greater 
force  unless  the  abdominal  muscles  or  diaphragm  be  called  into  action. 

This  "cut-off"  then  controls  urination  in  health:  relaxed,  the 
urine  flows;  voluntarily  contracted  during  any  part  of  the  act,  the 
stream  is  cut  off  as  sharply  as  if  by  a  knife. 

Some  erectile  tissue  and  a  good  deal  of  unstripcd  muscle  are  found 
around  this  as  well  as  around  all  other  joortions  of  the  virethra,  but 
the  function  of  the  cut-off  muscle  must  be  kept  clearly  in  view,  on 
account  of  its  bearing  upon  catheterism  and  sj)asmodic  stricture. 

The  membranous  urethra  is,  of  all  parts,  the  most  positively  fixed. 
There  is  no  marking  on  the  mucous  lining  of  the  canal  to  indicate  any 
division  between  it  and  the  spongy  portion.  The  separation  into  parts 
is  arbitrary.  The  prostatic  urethra  bores  the  prostate,  sometimes 
barely  covered  by  that  organ  above,  sometimes  surrounded  by  a  con- 
siderable thickness  of  the  same. 

Unstriped  muscle,  of  which  the  prostate  is  mainly  composed,  sur- 
rounds the  urethra  from  one  end  to  the  other,  and  enters  largely  into 
the  erectile  structures  of  the  penis  as  well. 

The  diameter  of  the  normal  urethra  varies  even  more  than  its 
length — it  has  been  estimated  at  from  two  to  six  lines,  A  fair  average 
is  not  larger  than  three  tenths  of  an  inch — about  No.  27,  French 
scale.  But,  whatever  its  size,  the  urethra  is  not  a  tube  of  uniform 
caliber  from  end  to  end.  It  has  naturally  three  points  of  j^hysiological 
narrowing — one  at  the  meatus  ;  the  second  commencing  about  one  inch 
back,  and  being  most  pronounced  somewhere  in  the  third  inch,  some- 
times at  three  and  a  half  inches  ;  the  third  point  of  narrowing  being 
the  point  of  entrance  into  the  triangular  ligament.  The  meatus  is 
normally  the  narrowest 
point.  The  two  points 
of  enlargement  are  the 
fossa  navicularis  (so 
called  from  its  supposed 
resemblance  to  a  boat), 
v;hich  is  situated  just 

inside  the  meatus,  and T ' 

the    bulbous    urethra,  Fig.  7  {Tiiompson). 

OCCUPVing'     a      position  '^'  ^'  ^^'^  '^  represent  the  prostatic,  membranons,  and  spongy 

>■  J      ^  t  portions. 

immediately    in    front 

of  the  triangular  ligament.  Of  the  two,  the  latter  is  the  larger.  The 
urethra  enlarges  again  in  the  prostate  (prostatic  sinus).  Fig.  7,  from 
Thompson,  shows  these  points  in  diagram. 

In  the  fossa  navicularis  lies  the  valvule  or  lacuna  magna  (Fig.  8), 
a  little  mucous  flap  on  the  roof  of  the  urethra  about  half  an  inch  from 


32 


DISEASES   OF   THE   URETHRA. 


the  meatus,  shut  ting  in  a  fossa  about  two  lines  deep.     In  this  yalvule 
the  points  of  small  instruments  arc  liable  to  become  engaged.     There 
are  other  blind  j)ouches  or  lacuna^  of  variable  size  scattered  along  the 
urethra,  chielly  on  its  roof,  and  known  as  the 
sinuses  of   Morgagui.     They  run    ))arallcl  with 
the  urethra  for  perhaps  half  an  inch,  and  ter- 
minate in  a  cul-de-sac.     Cruveilhier  found  one 
an  inch  long.     The  openings  of  these  sinuses  all 
look   toward  the   meatus,  and  are  often   large 
enough  to  receive  the  points  of  filiform  instru- 
ments, a  fact  to  be  remembered  in  manipulatiu:^ 
Avith  fine  bougies  (sec  Fig.  31).     Another  lacuna 
in  the  urethra,  which  may  catch  the  point  of  a 
fine  instrument,  is  the  sinus  iiocularis  (Guthrie) 
or  utriculus  of  the  prostate,  a  deep  little  depres- 
sion running  down  in  front  of  and  underneath 
the  veru  montanum. 
The  mucous  glands  of  the  urethra  are  small  clusters  of  minute  fol- 
licles, very  abundant,  opening  either  on  the  free  surface  of  the  mem- 
brane or  into  the  sinuses  of  Morgagni. 


Fig.  8  (CnieeUhie)-). 


Fio.  0  (Crureithier). 
Vertical  section  tlirough  glans  and  fossa  naviculari?. 


Fig.  10  {Cruveilhier). 
Transverse  section  of  penis. 


Cowper's  glands  are  small,  round,  lobular  bodies  about  the  size  of 
cherry-stones,  lying  just  behind  the  bulb  of  the  urethra  in  tlie  trans- 

verso-urethral  muscle.  Their  ducts  are 
sometimes  very  long,  but  average  a  full 
inch,  and  open  into  the  floor  of  the  ure- 
thra. Their  fiuid  is  supposed  to  aid  in  di- 
luting the  sperm.  The  urethra  has  about 
the  same  amount  of  sensitiveness  in  health 
as  the  conjunctiva.  In  the  membranous 
urethra,  however,  sensibility  is  exaggerated. 
The  color  of  the  membrane  is  a  pale  pink. 
In  a  state  of  rest  its  walls  lie  in  contact, 
obliterating  the  cavity  of  the  canal,  so  that  a  cross-section  presents 
a  slit  instead  of  an  opening  (Figs.  0,  10,  and  11). 


Fig.  11  (Cruveilhier). 

Transverse  section  of  center  of 
prostate.  IJ.  EJaculatory  ducts. 
Sp,  Sinus  pocularis. 


CURVE   OF   THE   URETHRA.  33 

CuKVE  OF  THE  Ueetiira. — In  connection  with  tlie  anatomy  of 
the  urethra,  it  is  advisable  to  give  some  details  of  explorations,  and  of 
catheterism  and  the  use  of  instruments  in  the  normal  canal. 

The  lowest  point  of  the  urethra  is  just  in  front  of  the  triangular 
ligament,  where  it  lies  about  one  inch  beneath  the  symphysis  pubis. 
From  this  to  the  meatus  the  canal  takes  any  position  according  to  the 
direction  given  the  penis ;  toward  the  neck  of  the  bladder,  however, 
the  urethra  is  said  to  have  a  fixed  curve.  This  is  not  strictly  true,  for 
straight  instruments  may  enter  the  bladder — a  proceeding  sometimes 
difficult,  often  painful,  never  absolutely  indispensable,  if  indeed  neces- 
sary. At  rest,  however,  the  urethra  has  a  curve  which,  in  the  mem- 
branous portion,  is  fixed,  and  runs  on  an  average  at  a  distance  of 
from  two  fifths  to  three  quarters  of  an  inch  from  the  symphysis  pubis. 
It  varies  slightly  with  individuals  and  in  the  same  individual  at  differ- 
ent periods  of  life,  being  shorter  and  sharper  in  the  child,  longer  in 
the  old  man.  A  distended  bladder  or  enlarged  j^rostate  lengthens  the 
curve. 

The  proper  average  curve,  as  recognized  since  Sir  Charles  Bell,  and 
insisted  on  by  Sir  Henry  Thompson,  the  one  which  will  mathemati- 
cally accord  with  the  greatest  number  of  urethras,  is  that  of  a  circle 
three  and  one-quarter  inches  in  diameter  ;  and  the  proper  length  of 
arc  of  such  a  circle,  to  represent  the  subpubic  curve,  is  that  subtended 
by  a  chord  two  and  three-quarter  inches  long.*  An  instrument  made 
with  a  short  curve  of  this  description  will  readily  find  its  way  through 
the  normal  urethra  into  the  bladder  without  the  employment  of  any 
force.  It  is  very  desirable  that  instruments  intended  for  habitual  use 
should  be  so  constructed,!  inasmuch  as  many  of  the  difiiculties  of 
catheterism  arc  due  to  a  defective  curve  in  the  instrument  employed. 
The  defect  most  frequently  encountered  is  a  too  great  straightness  of 
the  last  half-inch — a  deviation  of  the  curve  at  its  most  important 
point.  In  an  instrument  properly  made  (Fig.  12)  it  will  be  found 
that  a  tangent  to  the  axis  of  the  curve  at  its  extremity  will  intersect 
the  projected  axis  of  the  shaft  at  a  little  less  than  a  right  angle  {n  h 
h).  If  the  curve  comprised  only  a  quarter  of  the  circle,  the  tangent 
would  meet  the  projected  shaft  at  a  right  angle  (m  g  h)  ;  but  instru- 
ments made  of  this  length  and  a  little  longer,  as  they  are  usually 
found,  invariably  have  the  last  part  of  the  curve  tilted  off  into  a 
faulty  direction,  as  shown  in  the  plate  (Fig.  12),  making  the  angle 
between  a  tangent  to  the  axis  of  the  curve  at  this  point  and  the  pro- 

*  "  In  the  winter  of  1852-53,  assisted  by  the  late  Dr.  Isaacs,  I  made  a  series  of  care- 
ful experiments  upon  sections  of  frozen  subjects,  as  well  as  by  injecting  the  urethra  with 
numerous  substances,  afterward  carefully  cutting  out  the  casts.  I  found  the  average 
curve  to  be  identical  with  the  one  given  above." — Van  Buren. 

f  An  instrument  destined  for  habitual  use  by  the  patient  is  sometimes  made  half  an 
inch  short  in  the  curve,  on  account  of  the  greater  ease  of  introduction  of  such  an  instru- 
ment through  the  pendulous  urethra. 
3 


34 


DISEASES  OF  THE   URETHRA. 


jected  axis  of  the  shaft  obtuse 
{I  j  h),  and  falling  within  the 
right  angle. 

Fig.  13.  a  and  h  represent 
faulty  curves — still  occasionally 
encountered  on  instruments. 
Fig.  14  shows  the  correct  curve. 

It  is  better  to  prolong  the 
curve  around  the  circle,  and 
even  slightly  decrease  that  of 
the  terminal  quarter  of  an  inch, 
as  instruments  so  made  are  less 
liable  to  be  defective,  and  the 
point  is,  for  all  practical  pur- 
poses, still  at  right  angles  to  the 
shaft,  and  one  and  three-quarter 
inch  from  it.  A  knowledge  of 
this  relative  position  and  direc- 


>/Z 


ITd 


Fio.  12.— Instruments  as  ordinarily  made,  with  faulty  curve,  (9a,  0(/ fB6niqn6).  Correctly-curved 
conical  instrument,  Ob.  Length  of  natural  curve  of  urethra,  / 0  A.  Length  of  chord  of  curve 
of  sound,  h  0,2xg  inches. 

tion  of  the  point  is  of  great  importance  in  difficult  catheterism.     A 
moderately  short  curve  is  as  good  as  a  long  one,  provided  it  is  accu- 


FiG.  13.— Faulty  curves. 

rate  ;  indeed  better,  for,  when  the  instrument  is  made  with  the  full 
length  of  curve,  three  tenths  of  the  circle,  that  portion  subtended  by  a 

chord  of  two  and  three-quarter  inches, 
its  point  is  so  far  from  the  shaft  that 
it  is  sure  to  "  wabble  "  when  the  point 
encounters  an  obstruction.  This  ob- 
jection is  all  the  more  api^licable  to 
the  Benique  instrument  (Fig.  12, 
(/  h  o),  on  account  of  its  having  a 
Fig.  i4.-Proper cune.  postcrior  as  wcll  as  an  anterior  curve. 


CATIIETEPJSM. 


35 


This  "wabbling"  is  not  of  serious  importance  in  the  healthy  canal, 
but  it  is  very  distracting  to  the  surgeon  when  a  tight  stricture  is  to 
be  entered.  Here  the  short  conical  point,  at  right  angles  to  the  shaft 
and  one  and  three-quarter  inch  from  it,  is  vastly  superior  on  account 
of  steadiness,  and  is  equally  certain  to  follow  the  urethral  curve  accu- 
rately. 

Exploration  of  the  Urethra — Catheterism. — The  introduc- 
tion of  a  sound,  staff,  or  catheter  into  the  bladder  is  generally  spoken 
of  as  "  catheterism."  The  use  of  the  staff  or  sound  is  sometimes  denomi- 
nated ''sounding."  The  manoeuver  in  either  case  is  the  same.  There 
being  given  a  canal  of  certain  dimensions  and  curvature,  and  an  instru- 
ment to  fit  it,  the  problem  is  to  introduce  the  latter  into  the  former. 
Nothing  is  easier,  although  to  perform  the  operation  perfectly  is  less 
simple  than  would  at  first  appear.  No  amount  of  instruction,  no  vol- 
umes of  directions,  can  teach  the  student  how  to  pass  the  sound.  He 
must  learn  by  doing  it,  first  upon  the  dead,  then  upon  the  living  body. 
Some  suggestions  may,  however,  be  given. 

Always  make  the  patient  lie  down  on  his  back,  with  his  head  on  a 
pillow,  his  legs  slightly  separated,  his  body  relaxed,  his  fears  quieted, 
and  himself  as  comfortable  as  possible.  Both  hands  should  be  practiced 
in  introducing  the  sound,  and  the  surgeon  should  keep  his  elbow  sup- 
ported during  most  of  the  operation,  in  order  that  his  hand  may  be 
more  steady.  If  the  right  hand  is  used,  the  surgeon  places  himself 
at  the  patient's  left,  and  vice 
versa.  To  explore  the  canal, 
a  simple,  blunt,  steel  instru- 
ment, of  medium  size,  is  se- 
lected, and  properly  -warmed. 
The  penis  is  gently  encircled 
by  the  fingers  and  thumb  of 
one  hand,  the  instrument  held 
lightly  with  the  points  of  three 
fingers  and  the  thumb  of  the 
other.  The  shaft  of  the  in- 
strument is  held  over  the  fold 
of  the  groin,  its  handle  nearly 
in  contact  with  the  skin,  from 
which  latter  (the  integument, 
first  of  the  groin  and  then  of 
the  abdomen)  it  is  not  to  be 
moved  away  until  the  point  of  the  instrument  is  about  to  enter  the 
fixed  portion  of  the  urethra  (membranous).  The  instrument,  at  first 
held  along  the  groin,  with  its  point  high  and  handle  low  (Fig.  15), 
is  entered  at  the  meatus,  and  the  penis  is  molded  up  over  it.  It  is 
not  pushed  into  the  urethra,  but  the  urethra  is  made  to  swallow  the 


Fig.  15. 


36 


DISEASES  OF  THE  URETHRA. 


Fig.  16. 


instrument,  as  it  were.  When  the  curve,  and  perhaps  an  inch  of  the 
shaft,  has  disappeared  within  the  meatus,  the  handle  of  the  instru- 
ment is  swept  around  over  the  surface  of  the  helly,  so  as  to  lie  exactly 

over  the  linea  alba,  i)aral- 
lel  with  it,  and  still  close 
to  the  integument  (Fig. 
IG).  The  whole  shaft  of 
the  instrument  is  now  to 
be  gently  pressed  toward 
the  feet,  being  still  kept 
close  to  and  parallel  with 
the  surface  of  the  belly 
(the  penis,  meanwhile, 
being  lightly  grasped  be- 
hind the  corona  glandis, 
and  held  steady).  The 
point  of  the  instrument  should  be  followed  Avith  the  little  linger  of 
the  hand  which  manages  the  penis,  and,  when  it  gets  fairly  past  the 
peno-scrotal  angle,  the  whole  scrotum,  with  the  testicles  and  penis, 
should  be  largely  seized  with  the  hand  and  pressed  up  against  the 
pubis,  with  slight  upward  traction.  The  point  may  now  be  felt  to 
settle  down  and  adapt  itself  to  the  sub-pubic  curve,  whence  on,  the 
weight  of  the  instrument,  properly  directed,  should  carry  it  into  the 
bladder. 

As  soon  as  the  curve 
lies  well  against  the  sym- 
physis, the  scrotum,  tes- 
ticles, and  penis  should  be 
dropped  ;  the  hand  which 
held  them  takes  the  instru- 
ment, simply  steadies  it 
in  the  median  line,  and 
gradually  carries  the  shaft 
away  from  the  abdomen 
(Fig.  17),  making  the  han- 
dle describe  the  arc  of  a 
circle,  and  depressing  the 
shaft  between  the  thighs 
until  it  lies  nearly  in  the 

same  plane  with  them.  No  pushing  movement  should  be  imparted 
to  the  instrument  during  this  time.  The  handle  is  simply  made  to 
describe  the  arc  of  a  circle,  and  the  point  in  a  healthy  urethra  can 
not  go  astray.  While  the  instrument  is  being  depressed  between  the 
thighs,  the  free  hand  is  employed  in  pressing  down  upon  the  mons 
veneris  and  root  of  the  penis  (Fig.  18),  to  stretch  the  suspensory  liga- 


FiG.  17. 


CATHETERISM. 


37 


Fig.  18. 


ment — a  point  of  importaTicc  to  the  easy  introduction  of  an  instru- 
ment, and  one  which  supplies  to  the  short  curve  all  the  advantages 
claimed  for  the  longer  Benique  curve.     When  the  instrument  is  in 
the    bladder,    its    point 
may    be    moved    freely 
from  side  to  side  by  partly 
rotating  the  handle. 

The  instrument 

should  be  withdrawn 
with  the  same  slowness 
and  care  with  which  it 
was  introduced.  No 
traction  is  needed.  The 
motions  used  in  intro- 
duction are  simply  re- 
versed. The  handle  of 
the  instrument  is  lightly 

caught,  and  without  traction  made  to  describe  the  arc  of  a  circle  until 
it  touches  the  abdomen  over  the  linea  alba.  It  is  then  carried  around 
to  the  groin,  and,  by  a  tilting  motion,  unhooked  from  the  urethra, 
ending  exactly  where  it  commenced  along  the  groin,  the  handle  low, 
the  point  high. 

The  first  principle  of  instrumentation  in  the  urethra  is  to  avoid  the 
use  of  force.  Even  in  a  healthy  subject,  sometimes,  the  beak  of  the 
instrument  will  become  arrested  by  contraction  of  the  unstriped  mus- 
cle surrounding  the  canal.  A  little  patient  waiting  will  overcome 
this,  and  the  instrument  glides  on.  The  arrest  of  a  sound  from  mus- 
cular contraction  usually  occurs  at  the  entrance  of  the  membranous 
urethra  from  spasm  of  the  '*  cut-off"  muscle  (spasmodic  stricture). 
The  practiced  touch  rarely  fails  to  detect  at  the  handle  of  the  instru- 
ment the  slight  contractions  of  the  muscular  fibers  around  its  point, 
and  in  this  way  diagnosis  with  organic  stricture  is  easy.  Gently  hold- 
ing the  instrument  in  place  for  a  few  minutes,  with  slight  forward 
pressure,  will  tire  out  the  muscles,  and,  if  the  obstruction  is  muscular, 
the  sound  will  shortly  pass. 

At  this  same  point  any  instrument  is  liable  to  be  arrested  mechani- 
cally in  a  healthy  urethra  by  the  triangular  ligament.  Here,  it  will 
be  remembered,  the  urethra  is  narrower  than  anywhere  else  within 
the  orifice,  and  just  in  front  of  this  point  exists,  naturally,  the  greatest 
width  of  urethra.  Now,  if  the  canal  be  flabby,  or  the  instrument  not 
large  enough  to  distend  it  (a  small  sound  is  more  liable  to  catch  here 
than  a  large  one),  the  point  may  become  arrested  along  the  floor  by 
the  triangular  ligament,  or  along  the  roof  (more  rarelv)  in  the  little 
fossa  lying  above  the  edge  of  the  subpubic  ligament.  The  instrument 
is  known  to  be  arrested  by  the  bulging  out  of  its  curve  in  the  perina- 


38  DISEASES  OF  THE  URETHRA. 

um  as  the  shaft  is  being  depressed  between  tlie  thighs  and  the  rebound 
of  the  handle  when  liberated.  The  obstacle  is  overcome  by  gently 
nianaHiveriug  the  point  of  the  instrument  by  partial  withdrawal  and  re- 
introduction  or  by  slight  depression  of  the  beak,  then  lifting  it  over 
the  obstacle  with  a  finger  in  the  perinfeum,  at  the  same  time  pulling 
up  the  point  of  the  instrument  to  make  it  sweep  the  roof  of  the  canal. 
This  will  generally  render  the  introduction  of  a  finger  into  the  rectum 
unnecessary.  The  dangerous  *'  tour  de  mAitre  "  *  might  be  gently  tried, 
but  no  force  should  ever  be  used  in  any  manipulations  at  this  point,  as 
a  false  passage  is  easily  made  here  and  under  these  very  circumstances. 
The  depression  of  the  handle  of  the  instrument  alone  is  capable  of  ex- 
erting enormous  power.  The  sound  represents  a  lever  of  the  first 
order,  and  the  surgeon  has  the  long  arm. 

With  a  little  patience  a  suitable  instrument  will  always  pass  into 
the  bladder  unless  there  is  stricture.  When  the  point  has  traversed 
the  membranous  urethra,  it  must  continue  on  freely  if  the  prostate  is 
normal.  The  so-called  spasm  of  the  neck  of  the  bladder  does  not  ex- 
ist as  an  obstruction  to  the  passage  of  instruments. 

Instruments  small  enough  to  engage  in  the  sinuses  of  Morgagni  are 
not  used  in  the  healthy  canal.  Instrumentation  m  morbid  conditions 
will  be  detailed  in  connection  with  the  different  diseases  requiring  it. 

A  silver  catheter  is  introduced  in  the  same  manner  as  the  sound. 
In  using  soft  instruments  without  a  stylet  the  penis  is  slightly  pulled 
upon,  so  as  to  efface  any  circular  folds,  and  the  instrument  is  pushed 
straight  onward  into  the  bladder.  If  it  gets  arrested,  partial  with- 
drawal and  rotation  during  the  next  forward  movement  will  cause  it 
to  pass. 

No  instrument  should  enter  the  urethra  unless  it  is  smooth,  pol- 
ished, and  well  oiled.  Warmed  oil,  thrown  into  the  canal  with  a 
syringe,  greatly  facilitates  the  passage  of  instruments. 

The  sensation  exiierienced  by  the  healthy  urethra  is  that  of  hot 
points  pricking  the  canal  along  the  part  being  traversed  by  the  foreign 
body.  As  the  instrument  enters  the  membranous  urethra,  a  desire  to 
urinate  begins  to  be  felt,  which  increases  as  the  prostate  and  neck  of 
the  bladder  become  distended  by  the  instrument,  so  that  the  patient 
sometimes  believes  that  urine  is  flowing  away,  in  spite  of  the  sur- 
geon's assertions  and  his  own  observation  to  the  contrary.  Nausea, 
and  even  syncope,  may  occur  as  the  instrument  distends  the  prostate, 
especially  on  the  first  introduction  in  sensitive  young  peojile.  Occa- 
sionally distention  of  the  prostatic  sinus  produces  a  partial  venereal 
orgasm. 

*  The  tour  dc  mditre  consists  in  introducing  a  sound  with  the  shaft  between  the  legs 
until  the  point  is  arrested  at  the  bulb.  Then  the  handle  is  rapidly  made  to  describe  a , 
semicircle  until  it  reaches  a  vertical  position,  when  it  is  at  once  depressed  between  the 
thighs.     It  is  brilliant,  effective,  but  dangerous. 


DEFORMITIES   OF   THE   URETHRA.  09 

If  the  patient  faints,  the  instrument  should  be  withdrawn  at  once 
and  the  legs  elevated,  while  the  head  is  hung  over  the  edge  of  the 
lounge  upon  which  he  has  been  lying.  The  facility  with  which  this 
may  be  done,  if  necessary,  is  one  of  the  reasons  for  placing  the  patient 
on  his  back. 

DEFORMITIES  OF  THE  URETHRA. 

The  urethra  is  subject  to  arrest  and  error  of  development,  but  is 
not  often  seriously  deformed.  Among  curiosities  of  deformity  may  be 
mentioned  the  abnormal  position  of  the  meatus  on  the  side  of  the  glans 
penis  ;  the  termination  of  the  ejaculatory  ducts  in  a  separate  canal, 
running  along  the  dorsum  of  the  penis  and  opening  behind  the  glans  * 
(gonorrhcea  of  this  canal  has  been  noted)  ;  termination  of  the  urethra 
in  the  groin,  f  Perkowsky  J  found  in  a  well-formed  penis,  besides  the 
healthy  urethra,  a  second  canal  opening  at  the  base  of  the  glans  and 
affected  with  gonorrhoea.  He  split  this  subcutaneous  canal  to  the 
symphysis,  where,  he  says,  it  terminated  in  a  blind  pouch.  Luxardo  * 
describes  a  gonorrhoeal  patient  who  had  three  openings  at  the  end  of 
the  penis.  One  gave  exit  only  to  semen.  The  two  lower  ones  ap- 
peared to  communicate,  and  both  had  gonorrhoea.  E.  B.  Ward  |  re- 
ports three  brothers,  each  of  whom  had  a  triple  opening  to  the  ure- 
thra, but  he  does  not  state  whether  they  communicated  or  that  one 
was  not  a  seminal  duct.  Chopart  ^  reports  of  a  patient  of  seventeen 
that  he  had  never  passed  water  by  his  penis,  but  had  a  constant  watery 
diarrhoea.  His  ureters  opened  into  his  rectum  ;  but  he  doubtless  had 
a  penis,  for  he  is  stated  never  to  have  urinated  "par  la  verge."  When 
the  penis  is  absent  the  bladder  is  usually  also  lacking  in  these  cases, 
and  the  ureters  discharge  into  the  rectum.  No  case  of  double  urethra 
is  known,  except  with  double  penis.  Valvules  pointing  backward 
(Guyon)  occasionally  exist  congenitally  in  the  urethra,  and  partially 
prevent  the  outward  flow  of  urine.  They  are  found  about  the  veru 
montanum,  or  near  the  bladder.  Congenital  stricture  has  been  ob- 
served by  Nelaton,^  by  James  Syme,  and  by  many  others.  J  Con- 
genital urethral  dilatations  of  great  size  have  been  observed  in  a  few 
cases,  attended  by  atrophy  of  the  corpus  spongiosum  at  the  dilated 
point.  Their  relief  is  effected  by  cutting  away  the  redundant  tissue, 
accurately  coapting  the  edges  of  the  wound,  and  treating  as  for  longi- 
tudinal incision  of  the  urethra. 

All  the  foregoing  anomalies  are  exceedingly  rare.     There  are  other 

*  Cruveilhier,  op.  cii.,  p.  420.  f  Haller,  quoted  by  Pitha,  op.  cit. 
X  "  Centrlbltt.  f.  Chir.,"  No.  50,  1883,  p.  816. 

*  "L'Union  Medicale  "  (an  Italian  reference),  Xo.  54,  1883,  p.  663. 
II  "New  York  Medical  Record,"  September  1,  1383,  p.  251. 

^  "  Maladies  des  Voies  urinaires,"  1830,  p.  325. 

^  Phillips,  "  Traite  des  Maladies  des  Voies  urinaires,"  p.  2*71. 

^  "  British  Medical  Journal,"  p.  1,  1862. 


40  DISEASES   OF  THE    URETHRA. 

deformities,  however,  which  are  more  common,  namely — impcrfora- 
tion,  atresia,  hypospadias,  and  epispadias. 

Impekfouation  axd  Atresia. — The  meatus  alone  may  be  imper- 
forate (or  sti'ictured),  or  any  portion  of  the  canal  may  be  obstructed 
by  a  membranous  partition,  or  replaced  by  a  fibrous  cord :  in  these 
cases  the  urachus  sometimes  continues  open  for  the  escape  of  urine. 
Joseph  Englisch  *  has  furnished  a  contribution  to  this  subject. 

If  the  meatus  alone  is  occluded,  an  opening  is  made  at  the  point 
where  it  ought  to  be,  and  the  healing  of  the  Avound  prevented  by  daily 
use  of  bougies.  If  a  diaphragm  exists  farther  down,  it  may  be  punc- 
tured with  a  fine  trocar.  The  same  instrument  may  be  used  where 
there  is  atresia,  the  point  being  pushed  along  the  course  which  the 
urethra  naturally  follows.  If  the  atresia  involves  a  portion  of  the 
pendulous  urethra  only,  success  may  be  hoped  for.  The  bleeding  is 
not  great,  and  may  be  arrested  by  cold  and  pressure.  When,  how- 
ever, the  whole  urethra  is  replaced  by  a  fibrous  cord,  the  prognosis  is 
very  bad.  A  direct  opening  from  the  perinoeum  into  the  bladder 
would  be  the  most  judicious  surgical  proceeding  in  these  cases,  the 
urethra  being  attended  to  afterward.  Without  a  previous  opening  in 
the  perineum,  a  fine  trocar,  a  blunt  tenotomy-knife,  or  a  silver  probe 
may  be  used,  to  cut  and  break  down  the  connective  tissue  occupying 
the  position  where  the  urethra  ought  to  be,  and  this  maybe  continued 
on  from  the  meatus  into  the  region  of  the  neck  of  the  bladder. 
Sometimes  immediate  success  crowns  this  desperate  course,  while  again 
the  attempt  has  been  abandoned,  and  after  a  number  of  hours  urine 
has  found  its  way  out  through  the  artificial  opening.  Interesting 
cases  have  been  collated  by  Guyon  f  and  Demarquay.  Such  openings 
necessarily  tend  to  recontract,  and  must  be  constantly  kept  dilated. 

Hypospadias  axd  Epispadias  are  the  most  common  congenital 
deformities  of  the  urethra.  According  to  Baron,  J  epispadias  occurs 
once  for  one  hundred  and  fifty  cases  of  hypospadias,  but  Marchal  did 
not  find  a  single  case  of  epispadias  in  examining  sixty  thousand  con- 
scripts. Rennes  *  states  that  a  military  surgeon  found  ten  cases  of 
hypospadias  among  three  thousand  conscripts.  Hypospadias  descends 
sometimes  by  inheritance. 

Hypospadias  (utto,  heneath  ;  (nrd^w,  I  divide). — This  deformity 
consists  in  an  arrest  of  development  of  a  portion  of  the  lower  wall  of 
the  urethra,  its  lateral  halves  failing  to  unite  in  the  median  line.  Ko- 
bclt  II  gives  a  representation  of  the  injected  separate  halves  of  the  cor- 

*"Ueber  angeborene  Vcrschliessungen,"  etc.,  "Arch.  f.  Kindcrheilkuntle,"  Bd.  ii, 
1S81,  pp.  85  and  291. 

f  "  Des  Vices  dc  Conformation  do  I'Urethre  chez  rilomme  ot  dcs  Moyens  d'y  rem6- 
dier."     Th5se,  Paris,  1863,  and  Demarquay,  op.  dt.,  p.  581. 

\  Quoted  by  Dolbeau,  "De  1' Epispadias,"  etc.,  Paris,  1801,  p.  11. 

*  "  Obs.  med.  sur  (luelques  Maladies  rares,"  etc.,  "Arcli.  G6n.  de  M6d.,"  1831,  Ixxvii, 
p.  1.  I  "  De  I'appareil  du  sens  genital,"  etc.,  1851,  pi.  1,  fig.  2,  and  p.  96. 


DEFORMITIES   OF  THE   URETHRA.  41 

pus  spongiosum  in  a  case  of  hypospadias.  The  embryo  at  two  months 
has  hypospadias  normally.  The  scrotum  has  not  yet  united,  and,  if 
natural  evolution  ceases  here,  the  last  degree  of  hypospadias  results 
with  bifid  scrotum.  Hypospadias  may  occur  at  any  jooint  in  front  of 
the  membranous  urethra,  but  does  not  involve  the  latter  or  the  pro- 
static portion  of  the  canal ;  consequently,  no  matter  how  extensive 
hypospadias  may  be,  the  patient  has  control  over  the  escape  of  urine. 
"When  hypospadias  is  scrotal,  the  penis  is  usually  very  imperfectly  devel- 
oped, imperforate,  and  looks  like  a  large  clitoris.  The  bifid  scrotum 
passes  very  well  for  a  vulva,  and  in  this  way  some  of  the  so-called 
hermaphrodites  are  formed,  the  true  sex  perhaps  only  being  discovered 
after  adult  age  has  been  reached.  The  monstrosity  known  as  her- 
maphrodite does  exist,  but  is  excessively  rare.  To  constitute  a  true 
hermaphrodite,  there  must  be  penis  and  testicle,  uterus  and  ovary.* 

Hypospadias,  anterior  to  the  peno-scrotal  angle,  is  more  common 
than  the  scrotal  variety,  and  most  frequent  of  all  is  hypospadias  con- 
fined to  the  glans  penis  or  its  immediate  vicinity.  That  part  of  the 
urethra  lying  between  a  hypospadial  opening  and  the  meatus  is  usually 
absent  or  impervious,  but  maybe  patulous  for  a  short  distance  in  front 
of  the  opening  in  the  floor  of  the  urethra,  or  even  up  to  the  meatus. 
Hypospadias,  as  commonly  encountered  in  practice,  consists  of  an 
absence  of  the  fraenum  preputii,  and  a  flaring  open  of  the  meatus  in- 
feriorly,  or  an  inferior  opening  in  the  canal  within  a  few  lines  of  the 
natural  meatus,  the  position  of  which  is  usually  marked  more  or  less 
perfectly  in  its  usual  site.  The  glans  penis  may  be  bifid.  The  ure- 
thral orifice  in  hypospadias  is  small,  as  a  rule. 

The  only  disturbances  caused  by  hypospadias  are  functional.  The 
patient  may  not  be  able  to  pass  water  without  wetting  himself,  as 
in  scrotal  hypospadias,  and  if  the  opening  is  too  low  in  the  canal  he 
may  be  impotent,  from  inability  to  throw  the  semen  against  the  uter- 
ine orifice. 

Simple  hypospadias  rarely  calls  for  surgical  interference,  and  opera- 
tions which  have  been  performed  for  its  relief  are  not  over-encourag- 
ing in  their  results — that  is,  in  regard  to  restoring  large  portions  of 
the  canal — but  rapid  advances  are  now  being  made  in  this  direction 
(Duplay).t 

Hypospadias  of  the  glans  penis  is  unimportant ;  many  patients  pos- 
sess it  without  being  aware  of  the  fact.  It  may  be  necessary  to  enlarge 
the  opening  in  case  of  stricture  of  the  urethra,  in  order  to  introduce 
instruments  of  sufficient  size  to  accomplish  thorough  dilatation. 

*  Concei'ning  hermaphrodism,  may  be  consulted,  with  advantage,  the  extensive  work 
of  Isidore  Geoffroy  Saint-Hilaire,  "  Des  Hermaphrodismes  :  Hist.  gen.  et  prat,  des  Anoma- 
lies de  I'Organisation,"  etc.,  1836,  vol.  ii ;  and  art.  "  Hermaphrodism,"  "  Nouveau  Diet,  de 
M6d.  et  de  Chir.  pratiques,"  1873,  vol.  xvii,  p.  488. 

\  "  Arch.  Gen.,"  May  and  June,  18'74. 


42  DISEASES   OF   THE   URETHRA. 

Comph'cafion,^. — One  complication  of  serious  importance  may  occur 
with  hypospadias,  wliich  always  demands  operation.  It  is  where  the 
corpus  spongiosum  and  urethra  are  too  short,  so  that,  although  the 
meatus  urethrae  may  be  found  at  or  near  the  apex  of  the  glans,  still 
the  short  urethra  acts  like  the  string  of  a  bow,  and  keeps  the  penis 
curved  at  all  times,  particularly  during  erection.  The  patient  is  some- 
times retromingent.  The  penis  may  be  straightened  in  these  cases  by 
cutting  through  and  dissecting  up  the  fibrous  string  which  represents 
the  urethra,  and  letting  the  meatus  find  its  own  position  at  the  peno- 
scrotal angle.  Then  the  fibrous  septum  of  the  corpora  cavernosa 
must  be  cut,  and  deep  transverse  sections  made  in  the  sheath  of  the 
penis  beneath  the  corpora  cavernosa.  In  one  case  I  have  seen  a  por- 
tion of  the  integument  of  the  penis  slipped  in  to  cover  the  raw  area 
with  admirable  result.  I  have  succeeded  in  this  way  in  restoring 
thorough  erection,  and  I  know  one  patient  in  this  condition  who  mar- 
ried, to  his  satisfaction.  But  to  make  a  new  urethra  is  a  more  diffi- 
cult matter  ;  to  make  a  good  urethra  not  possible.  It  may  serve  as  a 
urinary  canal,  but  as  a  projector  of  semen  I  believe  that  a  tube  with- 
out retractile  walls  would  be  useless. 

To  straighten  a  penis,  Bouisson*  first  advised  division  of  the  sep- 
tum of  the  corpora  cavernosa  with  a  tenotome.  Physick,f  of  Phila- 
delphia, removed  a  V-shaped  piece  of  corpora  cavernosa  behind  the 
glans,  and  Pancoast  and  Gross  have  follo^ved  his  example.  T.  Auger  J 
first  operated  successfully  for  this  condition,  building  an  entire  new 
urethra  at  the  same  time,  but  Duplay's  *  method  is  a  better  one. 

Epispadias  (eVl,  above ;  a-n-a'Cui,  I  separate)  is  a  fissure  of  the  supe- 
rior wall  of  the  urethra  with  ectopia  of  the  canal  (Guyon).  It  is  very 
rare.  The  urethral  opening  may  be  upon  the  glans,  or  anywhere  along 
the  top  of  the  penis,  as  far  back  as  its  root.  When  the  membranous 
and  prostatic  urethra  are  involved,  there  is  also  exstrophy  of  the  blad- 
der. The  orifice  of  the  urethra  in  ei^ispadias  is  large.  Sometimes  a 
finger  may  be  passed  through  it  into  the  bladder,  that  part  of  the 
urethra  lying  in  front  of  the  opening  being  an  open  gutter.  Inconti- 
nence of  urine  is  frequently  observed  when  the  opening  is  far  back, 
especially  if  the  pubic  bones  are  separated. 

There  may  be  complete  epispadias  without  exstrophy  of  the  blad- 
der. Dolbeau  |  has  published  an  autopsy  of  this  condition,  with  plate. 
The  penis  is  short  and  thick  in  epispadias,  or  small  and  more  or  less 

*  "De  rilypospadias,"  etc.  ("Tribut  i  la  cliirurfrie  "),  Paris,  18G1,  vol.  ii,  p.  -187. 
f  "  A  Century  of  American  Medicine,"  1876,  pp.  188. 

X  "Hypospadias  p6no-scrotal,"  Paris,  1875,  pp.  15. 

*  "De  I'Hypospadias  p6no-scrotal,"  etc.,  "  Archiv.  Gen.,"  May  and  June,  1874,  and 
i')id.,  March,  1880,  p.  257. 

II  "  De  I'Epispadias,  ou  P^issiire  ur6thrale  superieure,  et  de  son  Traitement,"  p.  46, 
Plate  UI.    Paris,  1801. 


URETHRAL   AND   SEXUAL   IIYGIEXE.  43 

deviated.  The  pubic  bones  are  usually,  but  not  necessarily,  separated 
in  complete  and  sometimes  in  incomplete  epispadias.  There  may  be 
hernia  of  the  bladder,  without  positive  exstrophy.* 

Epispadias  is  an  arrest  of  development  in  the  upper  wall  of  the 
urethra,  but  it  is  still  a  matter  of  hypothesis  how  the  urethra  gets 
above  the  united  corpora  cavernosa ;  for,  even  when  the  genital  buds, 
which  are  to  form  the  corpora  cavernosa,  are  still  separate  at  the 
fortieth  day  of  fetal  life,  the  urethra  is  beneath  them.  The  fact, 
however,  remains,  as  proved  by  Dolbeau's  dissection,  that  the  ure- 
thra gets  above  the  corpora  cavernosa,  and  fails  to  unite  in  its  upper 
wall,  the  corpora  cavernosa  effecting  their  faulty  union  none  the 
less.  With  exstrophy  of  the  bladder,  where  the  lower  part  of  the 
abdominal  wall  is  absent,  and  the  pubic  bones  do  not  come  together, 
it  is  easier  to  understand  how  the  roof  of  the  urethra  may  be  wanting 
throughout. 

Treatment. — Mature  surgical  judgment  can  not  promise  a  cure 
from  operative  procedure  in  epispadias.  The  adaptation  of  a  proper 
urinal  is  the  best  treatment,  either  the  model,  advised  for  esstroj)hy 
(Fig.  75),  or  the  rubber  urinal  (Fig.  74).  Operations  which  have  been 
undertaken  very  often  fail,  erections  and  contact  of  urine,  with  small- 
ness  of  the  flaps,  being  the  chief  causes.  The  operations  which  have 
been  most -successful  in  covering  over  the  canal  are  those  of  J^elaton 
and  the  modification  by  Dolbeau.  They  consist  in  freshening  the 
edges  of  the  flattened  urethral  furrow,  and  bringing  down  over  it  a 
quadrilateral  flap  of  integument,  which  is  adjusted,  epithelium  inward. 
The  hairs  of  the  flap  must  be  removed  by  electrolysis.  The  raw  sur- 
face of  this  flap  is  in  its  turn  covered  by  sliding  flaps  (epithelium  out- 
ward) from  the  sides  of  the  penis ;  or  by  dissecting  up  a  flap  from 
the  scrotum,  leaving  it  attached  on  both  sides  and,  running  the  penis 
under  it,  so  as  to  bring  the  raw  surfaces  of  both  flaps  into  contact, 
separating  the  scrotal  flap  after  firm  union  has  been  effected.  Both  of 
these  operations  have  been  successful  in  roofing  in  the  canal,  but  the 
incontinence  of  urine  has  not  been  overcome,  f 

URETHRAL  AND  SEXUAL  HYGIENE. 

Before  passing  to  the  morbid  conditions  of  the  urethra,  its  hygiene 
in  health  and  disease  demands  consideration. 

That  the  urethra  may  be  in  a  healthful  state,  able  to  get  well  if 
diseased,  and  then  to  remain  well,  two  points  must  be  observed.  They 
comprise  fully  the  hygiene  of  the  canal.     They  are  : 

(1)  That  the  urine  be  non-irritating  in  character. 

(2)  That  sexual  excitability  be  quieted. 

*  "  Joum.  de  Med.,  Chir.  et  Pharm.,"  p.  14,  1S41. 

f  For  minute  details  of  the  operation,  see  Nelaton,  "  Traite  de  Pathologic  exteme," 
and  Dolbeau.     These  cit.  and  Dolbeau,  "Archiv.  Gen.,*'  March,  ISSO,  p.  257. 


44  DISEASES   OF   THE   rRETIIRA. 

(1)  Urine,  to  be  non-irritating,  miist  be  normal,  faintly  acid  or 
neutral,  free  from  sharp  crvstals,  and  not  too  concentrated.  Hence 
measures  tending  to  bring  the  fluid  to  this  state  are  hygienic.  These 
measures  include  general  hygiene  of  the  skin,  stomach,  muscles,  lungs, 
etc.,  but  also  in  many  cases  (especially  where  the  subject  is  of  gouty 
habit)  certain  dietetic  precautions.  The  latter  consist  in  the  avoid- 
ance of  all  alcoholic  fluids,  especially  sweet  fermented  wines  and  malt 
liquors.  New  ale  is  particularly  harmful.  All  of  these  substances 
tend  to  create  sharp  crystals  of  uric  acid  in  the  urine,  as  well  as  to 
concentrate  and  acidify  it.  From  this  cause  alone  inflammation  of  the 
urethra  may  spring.  Lemon-juice  is  also  somewhat  irritating  to  the 
urethra,  as  are,  to  a  mild  degree,  all  the  condiments,  salt,  pepper,  mus- 
tard, and,  it  is  said,  asparagus.  In  inflamed  states  of  the  canal,  gen- 
eral hygiene  prescribes  rest. 

(2)  The  quieting  of  sexual  excitability  is  an  object  not  less  im- 
portant, but  by  far  more  difficult  to  accomplish.  No  part  of  the  body 
can  be  in  perfect  health  unless  its  function  is  being  regularly  and  satis- 
factorily performed.  This  is  seen  in  stomach,  brain,  muscle,  excretory 
duct.  For  example,  when  all  the  urine  escapes  from  the  urethra, 
through  a  large  fistula  in  the  perinaeum,  the  fore  part  of  the  canal 
contracts  and  becomes  hyperaesthetic. 

The  urethra,  however,  only  performs  the  function  of  a  sexual  canal 
at  longer  or  shorter  intervals.  If  there  were  no  erotic  fancies,  the  ure- 
thra would  never  be  called  upon  to  participate  in  the  sexual  function, 
and  the  latter  would  have  no  influence  over  its  health  or  disease.  In 
the  eunuch  the  hygiene  of  the  urethra  undoubtedly  does  not  include 
the  sexual  problem. 

If,  then,  the  individual  be  absolutely  pure  in  thought,  word,  and 
deed  ;  if  he  never  has  or  has  had  an  erotic  fancy,  direct  or  remote,  then 
his  urethra  would  be  a  urinary  canal,  and  its  hj'giene  would  be  simple. 
But  absolute  purity  is  not  a  common  attribute  of  man,  as  anyone  who 
has  the  honesty  to  accept  facts  must  allow,  and  the  rule  that  every 
male  adult  has  more  or  less  strong  sexual  longings  and  necessities  must 
be  admitted.  Hence  is  establishod  the  rule,  borne  out  daily  and  hourly 
by  an  intelligent  study  of  the  parts  concerned,  both  in  health  and  dis- 
ease, that  the  urethra  is  not  in  the  best  conditions  for  health  unless 
the  sexual  needs  are  attended  to.  There  is  no  possible  means  of  acccftn- 
plishing  this  result  except  marriage.  Fornication  is  always  irregular, 
unnatural,  often  excessive,  and  therefore  is  harmful  and  worse  than 
nothing,  looked  at  from  a  merely  worldly  point  of  view.  Masturbation 
is  degrading,  and  bears  upon  the  whole  well-being  of  the  individual 
by  ruining  his  morale.  Nature's  safetj'-valve,  involuntary  ejaculation 
during  sleep,  is  inefficient.  Marriage  alone  allows  healthy,  natural, 
unstimulated  sexual  relations,  and  alone  accomplishes  the  first  neces- 
sity of  urethral  hygiene — namely,  sexual  quietude.     Hence  the  value 


INJURIES   OF   THE   URETHRA.  45 

of  marriage  as  a  curative  agent  in  morbid  conditions  of  the  urethra, 
especially  if  there  be  any  nervous  element  in  the  case — an  element 
which  is  almost  invariably  present  in  some  degree. 

In  all  conditions  of  acute  inflammation,  sexual  intercourse  must 
be,  of  course,  absolutely  interdicted.  Excessive  indulgence  is  bad  at 
•any  time,  but  worst  of  all  is  stimulation  without  relief.  This  state 
is,  unhappily,  a  common  one  among  the  unmarried  men  of  large 
cities.  Such  individuals,  looking  at  suggestive  pictures,  reading  ex- 
citing books,  taking  part  in  impure  conversation,  become  ripe  sub- 
jects for  nervous  disease  of  an  obscure  sort,  not  only  of  the  urethra 
but  of  the  whole  body.  In  fact,  this  undue  stimulation,  without 
appropriate  relief,  is  far  more  often  the  cause  of  hypochondria, 
melancholy,  and  functional  perversion,  than  is  the  masturbation  to 
which  the  public  generally  ascribe  it.  Nor  can  such  an  individual, 
by  any  plan  of  fornication,  escape  the  evil  consequences  to  which 
stimulated  but  ungratified  desire  exposes  him.  Marriage  with  a 
pure  woman  may  right  him — rarely  anything  short  of  this.  Hence, 
when  such  a  case  presents  itself  where  marriage  is  impossible,  or  if 
the  patient  be  already  unhappily  married,  there  is  but  one  course 
left  to  advise,  and  that  is  absolute  continence  and  an  effort  at 
purity  of  thought,  with  a  strict  avoidance  of  all  possible  tempta- 
tions to  erotic  thought  or  act,  whether  entering  through  the  mind, 
the  eye,  or  the  ear — whether  actual  or  implied,  direct  or  remote. 
Could  such  a  patient  imitate  the  heroic  example  of  St.  Augustin — 
a  record  of  which  that  honest  father  of  the  Church  has  left  behind — 
he  could  control  the  hygiene  of  his  urethra,  and  doubtless  save  him- 
self much  distress  in  life. 


INJURIES    OF    THE    URETHRA. 

Injuries  of  the  urethra,  of  seemingly  an  unimportant  nature, 
often  entail  serious  consequences.  From  the  position  of  the  canal, 
and  particularly  from  the  fact  that  it  runs  along  the  middle  line 
of  the  perinseum,  it  is  more  exposed  to  injury  than  any  other  por- 
tion of  the  genito-urinary  apparatus. 

Contusion"  of  the  pendulous  urethra  is  rare.  If  severe,  it  is 
followed  by  effusion  of  blood,  haemorrhage,  inflammation,  abscess, 
slough,  and  finally  traumatic  stricture — often  by  fistula,  with  loss  of 
substance.  Contusion  of  the  deep  urethra,  on  the  other  hand,  is 
quite  common.  The  sub-pubic  ligament  lies  directly  beneath  the 
symphysis  pubis,  filling  up  the  angle  made  by  the  junction  of  the 
two  bones.  This  ligament  is  nearly  as  hard  as  bone,  while  its  lower 
edge  is  thin  and  sharp.  In  all  falls  upon  the  perineum,  the  urethra 
lies  between  this  sharp  edge  and  the  body  upon  which  the  indi- 
vidual  falls.     The  injury  to   the   urethra  is   in   proportion  to  the 


46  DISEASES  OF  THE  URETHRA. 

force  of  the  blow  upon  the  perina?um.  The  caual  may  be  entirely 
cut  across,  or  more  or  less  crushed  transversely.  Injury  by  violence 
to  the  ])orin;vuin  involves  to  a  greater  or  less  extent  the  membra- 
nous uretlini  and  the  bulb  which  partly  overlies  it.  The  immediate 
results  are  swelling,  more  or  less  escape  of  blood  fi-om  the  injured 
bulb  into  the  surrounding  tissues,  often  haemorrhage  from  the  ure- 
thral orifice  ;  dilKculty  in  emptying  the  bladder,  perhaps  amounting 
to  absolute  retention  ;  possible  infiltration  of  urine  ;  perineal  abscess 
and  listula  ;  and  finally  traumatic  stricture  of  the  most  obstinate 
character.  Injury  to  the  perinasum  is  not  uncommon  at  any  age 
from  falling  astride  a  fence,  while  walking  on  it,  a  wheel,  while 
mounting  a  coach,  etc.  In  boys  a  kick  in  the  perinasum  is  often 
sufficient  to  damage  the  canal  permanently,  without  apparently  occa- 
sioning any  immediate  injury. 

Treatment. — If  the  patient  can  pass  water  and  there  is  no  infiltra- 
tion of  urine,  no  attempt  should  be  made  to  introduce  an  instrument 
into  the  bladder  immediately  after  contusion  of  the  urethra,  for  fear 
of  making  a  false  passage  at  the  injured  point  of  the  canal.  All 
means,  local  and  general,  must  be  used  to  keep  down  inflammation. 
If,  however,  there  is  retention,  either  immediate,  or  secondary  from 
inflammation,  and  warm  baths,  local  fomentations,  and  opiates  do  not 
relieve  it,  an  attempt  should  be  made  to  pass  a  soft,  French  olivary 
catheter  very  gently  into  the  bladder.  Failing  in  this,  a  long  filiform 
whalebone  bougie  may  be  tried  ;  and,  if  this  pass,  a  soft  catheter, 
open  at  both  ends  (Fig.  26),  may  be  made  to  enter  the  bladder  pushed 
along  upon  it  as  a  guide,  or  any  tunneled  instrument,  soft  or  solid, 
guided  in  the  same  manner.  If  the  bladder  cannot  be  readily  reached, 
perineal  section  should  be  at  once  resorted  to,  as  this  remedies  the 
retention,  and  is  the  best  treatment  for  the  traumatic  stricture  which 
will  inevitably  follow. 

If  a  soft  instrument  can  be  introduced  easily,  it  should  be  with- 
drawn after  the  bladder  has  been  relieved,  and  reintroduced  when 
necessary.  If  much  difficulty  is  experienced  in  passing  the  catheter 
the  first  time,  it  should  be  tied  in  and  left  for  a  day  or  two,  unless  it 
causes  the  patient  too  much  irritation,  and  then  be  withdrawn, 
cleaned,  and  reintroduced  at  intervals.  As  soon  as  the  inflammation 
following  the  injury  subsides,  the  passage  of  conical  steel  sounds  must 
be  commenced,  increasing  in  size  until  the  largest  instrument  is 
reached  which  the  meatus  will  admit,  and  this  must  then  be  intro- 
duced by  the  patient  himself  weekly  for  a  time,  and  then  at  appro- 
priate intervals  for  an  indefinite  period,  to  prevent  recontraction  of 
the  traumatic  stricture. 

If  infiltration  of  urine  has  taken  place,  large,  free,  dependent  in- 
cisions must  be  made  in  the  scrotum  and  perinaeum,  to  let  out  the 
urine  and  prevent  sloughing ;  the  scrotum  must  be  elevated,  and  qui- 


INJURIES   OF   THE   URETIIIIA.  47 

nine  and  iron  promptly  commenced  and  followed  up,  to  combat  fur- 
ther complications.  In  this  or  any  other  condition  of  serious  compli- 
cation or  difficulty,  the  soundest  surgery  demands  the  performance  of 
perineal  section  at  once,  inasmuch  as  this  course  not  only  provides  for 
a  free  issue  of  urine  (infiltrated  or  not),  but  puts  the  urethra  under 
immediate  control,  and  includes  the  proper  means  of  avoiding  trau- 
matic stricture. 

WOUHDS     INFLICTED     ON     THE     URETHRA     FROM     WITHOUT. — In 

children  severe  wounds  in  the  perineal  urethra  may  result  from  the 
breaking  of  the  earthen  vessel  upon  which  they  sit  to  empty  the 
bowels  and  bladder.  These  may  be  followed  by  infiltration  of  urine 
with  sloughing.  Any  part  of  the  urethra  is  liable  at  any  time  of  life 
to  ordinary  cutting  injuries,  inflicted  by  accident  or  design.  Fracture 
of  the  pelvis,  gunshot-wounds,  etc.,  may  damage  the  urethra  very 
seriously.  In  a  general  way  it  may  be  stated  that  wounds  of  the  ure- 
thra heal  more  readily  in  the  perinseum  than  elsewhere  (as  illustrated 
by  the  median  operation  for  stone),  and  are  not  apt,  in  this  region,  to 
be  followed  by  fistula,  unless  there  is  some  obstacle  to  the  free  escape 
of  urine  in  front  of  the  injury  (stricture).  Transverse  wounds  of  any 
portion  of  the  canal  are  followed  by  stricture  (Eeybard).*  Longitud- 
inal wounds,  correctly  coapted,  are  not.  Wounds  of  the  scrotum, 
extending  into  the  urethra,  are  more  liable  than  others  to  be  followed 
by  infiltration  of  urine,  on  account  of  the  looseness  of  the  connective 
tissue  of  the  part. 

Treatment  of  External  Wounds. — Wounds  involving  the  perineal 
urethra,  if  the  canal  be  healthy  (cuts  made  for  stone),  and  the  incision 
nearly  longitudinal,  may  be  left  to  granulate  without  interference. 
If,  however,  the  wound  is  transverse,  it  should  be  dilated  systemat- 
ically while  healing,  as  after  perineal  section  for  stricture.  Where 
the  pendulous  urethra  is  wounded,  the  following  course  should  be 
pursued  :  Unite  the  edges  of  the  wound,  at  once  and  very  accurately, 
with  the  finest  silk  suture.  Draw  off  the  urine  from  four  to  six  times 
in  the  twenty-four  hours.  The  catheter  should  be  small,  so  as  to  dis- 
turb the  process  of  repair  as  little  as  possible,  and  it  should  be  em- 
ployed often  enough  to  keep  the  bladder  from  becoming  distended. 
Should  the  bladder  .till,  a  little  urine  is  apt  to  be  forced  along  the  ure- 
thra outside  the  catheter  when  the  latter  is  introduced,  and  the  ob- 
ject of  using  the  instrument — to  keep  the  wound  from  the  contact  of 
urine — to  be  frustrated. 

When  the  surgeon  can  not  see  his  patient  often  enough  to  empty 
the  bladder  regularly,  a  catheter  of  pure  caoutchouc,  of  medium  size, 
should  be  first  introduced  into  the  bladder,  the  wound  united  over  it, 
and  the  instrument  tied  in,  corked,  to  be  opened  every  few  hours.  It 
should  be  retained  until  healing  is  complete.     The  rubber  is  better 

*  "Traite  pratique  sur  les  Retrecissements  de  I'llrethre,"  Paris,  1S53,  p.  67. 


48  DISEASES  OF  THE   URETHRA. 

than  any  harder  material.  Very  extensive  transverse  injuries  to  the 
urethra  may  be  remedied.  In  one  rcmiirkable  case*  tlie  whole  ure- 
thra and  four  liftlis  of  the  penis  were  cut  transversely  through  and 
yet  satisfactorily  repaired. 

Wounds  inflicted  upon  the  Urethra  from  within  are  mainly 
such  as  are  made  by  the  surgeon  in  careless  or  rough  manipulation 
(false  passage),  by  divulsion  of  stricture,  by  internal  urethrotomy,  by 
lithotomy  carelessly  performed — especially  in  children  where  the  ure- 
thra is  cut  or  torn  transversely — by  the  passage  or  rough  extraction  of 
stone  fragments,  the  introduction  of  foreign  bodies  by  the  patient,  etc. 
When  such  wounds  occur,  the  urine  comes  in  contact  with  the  raw 
surface,  and  ''  urethral  fever  "  is  the  common  but  not  inevitable  con- 
sequence. The  more  altered  and  decomposed  the  urine,  the  more 
liable  is  the  patient  to  suffer. 

URETHRAL    OR    URINARY   FEVER. 

This  peculiar  malady  is  better  known  in  its  symptoms  than  as  to  its 
cause.  Its  study  has  received  serious  attention  from  able  hands, f  but 
whether  it  is  neurotic  or  due  to  urinary  absorption  is  not  yet  clearly 
decided.     The  affection  may  assume  any  one  of  four  distinct  types  : 

1.  There  may  be  a  sharp  chill,  of  longer  or  shorter  duration,  com- 
ing on  anywhere  within  the  first  twenty-four  hours  (occasionally  later), 
after  manipulations  upon  the  urethra  or  bladder,  attended  by  an  eleva- 
tion of  the  temperature,  and  followed  by  fever  (with  perhaps  delirium) 
and  by  sweat.  After  this  there  is  no  further  trouble,  or  there  may 
follow  a  number  of  days  of  general  febrile  excitement,  malaise,  inap- 
peteuce,  loss  of  strength,  etc.,  and  slow  recovery,  or  other  paroxysms 
of  chill  and  fever,  with  more  or  less  complete  intermissions,  may  en- 
sue.    This  is  the  most  common  form. 

2.  There  may  be  only  a  few  slight  rigors  without  much  marked 
fever  or  any  sweating — these  passing  off  and  leaving  the  patient  as  well 
as  before. 

*  "Bull,  de  la  Soc.  de  Cliir.,"  tome  vii,  p.  550,  and  tome  viii,  p.  26,  d  seq. 

f  Girard,  "  Resorption  urineuse  et  Ur6mie  dans  les  Maladies  dcs  Voles  urinaires," 
Paris,  1873. 

Malherbe,  "  De  la  Fifevrc  dans  les  Maladies  des  Voies  urinaires,"  Those,  Paris,  1872. 

Banks,  "  Certain  rapidly  Fatal  Cases  of  Urethral  Fever  after  Catheterism,"  "  Edin- 
burgh Medical  Journal,"  1871,  p.  1074. 

Englisch,  "  Wien.  med.  Presse,"  No.  9, 1874. 

Gosselin  and  A.  Robin,  "  L'Urine  ammoniacal  et  la  Fievre  urineuse,"  Paris,  1874. 

Clark,  Sir  A.,  Discussion  on.  "Lancet,"  vol.  ii,  1883,  and  "Edin.  Med.  Jour.,"  April 
and  May,  1874. 

Morris,  H.,  a  most  suggestive  chapter  on  "  Urinary  Fever  in  Surgical  Diseases  of  the 
Kidney,"  American  reprint.  Lea  Brothers  &  Co.,  pp.  398-434. 

Harrison,  "On  Toxic  Urine  in  Relation  to  Certain  Surgical  Operations  on  the  Urinary 
Organs,"  "  Edin.  Med.  Jour.,"  July,  1886,  p.  251. 


URETHRAL   OR   URINARY   FEVER.  49 

3.  There  may  be  a  distinct  violent  chill  coming  on  rapifJly,  but  of 
variable  duration,  attended  by  intense  j)rostration,  alarm,  anxiety,  and 
excitement  at  first,  accompanied  by  violent  vomiting,  profuse  diarrhoea, 
coldness,  and  lividity  of  the  surface,  almost  total  suppression  of  urine, 
all  the  evidences  of  uraemia,  and  a  rapidly  fatal  issue. 

4.  There  may  be  slight  chill  and  fever,  followed  by  the  (usually 
rapid)  development  of  septicasmic  symptoms  and  death,  or,  more 
slowly,  by  true  pyasmia  and  death,  the  autopsy  revealing  abscesses  in 
the  prostate,  kidney,  liver,  lungs,  suppuration  in  the  joints  (knee, 
shoulder),  fluid  in  the  pleura,  pericardium,  etc. 

All  cases  can  be  arranged  under  these  heads.  The  first  two  are  by 
far  the  most  common,  and  fortunately  the  least  disastrous. 

That  all  these  disorders  should  depend  upon  the  simple  absorption 
of  urine  through  an  abraded  surface  is  in  the  highest  degree  improb- 
able. Other  forces  are  at  work,  and  these  are  probably  shock  and 
reflex  action,  suspending  the  function  of  the  kidneys,  often  already 
diseased.  The  condition  of  the  urine  also  has  much  to  do  with  the 
origin  of  urethral  fever.  It  produces  no  effect  in  contact  with  a 
wounded  surface,  when  it  is  normal,  being  sometimes  used  (in  France) 
as  a  dressing  to  fresh  wounds.*  When  in  ammoniacal  fermentation, 
it  is  undoubtedly  capable,  if  absorbed,  of  occasioning  septicaemic  and 
pysemic  phenomena,  and,  unfortunately,  in  bladder  and  urethral  dis- 
ease, the  urine  is  very  often  more  or  less  decomposed. 

The  mystery  about  urethral  fever  is,  that  it  does  not  occur  more 
constantly,  when  the  conditions  are  the  same.  The  majority  of  patients 
escape,  whether  the  urine  is  ammoniacal  or  not,  whether  the  wound  or 
the  violence  be  great  or  small.  The  same  patient  may  have  a  chill  one 
day  and  escape  it  after  an  exactly  similar  operation  on  the  next. 

The  simple  gentle  passage  of  a  small,  soft  bougie  may  give  rise  to  it, 
while  violent  divulsion  or  urethrotomy,  performed  a  day  or  two  after- 
ward, may  produce  no  such  result,  and  again  after  divulsion,  which 
has  been  negative,  the  passage  of  a  steel  sound  may  produce  a  chill, 
Nor  is  it  instrumentation  alone  which  is  the  exciting  cause,  since  pa- 
tients, upon  whom  no  instrument  has  ever  been  used,  have  well-marked 
exacerbations  of  chill  and  fever  in  connection  with  urethral  and  blad- 
der disease,  and  these  patients  cease  to  have  chills  (which  they  usually 
call  "  dumb  ague  ")  after  the  use  of  instruments  in  their  urethra  has 
dilated  the  stricture.  Other  patients  have  no  chill  until  dilatation  has 
reached  a  certain  limit,  after  which  every  effort  to  pass  an  instrument 
of  a  larger  size  is  liable  to  be  followed  by  urethral  fever.  The  extent 
of  the  injury  done  is  no  index  of  the  amount  of  fever  that  will  follow. 
The  gentle  passage  of  a  smooth  sound  may  cause  speedy  death,  while 

*  Dr.  Partridge,  at  my  suggestioD,  injected  sixty-minim  doses  of  healthy  urine  into  the 
subcutaneous  tissue  of  the  arm  of  many  patients  at  the  Charity  Hospital,  in  lSv3,  never 
exciting  suppuration. — Keyes.     (See,  also,  note  under  Extra yasation  of  Urise.) 
4 


50  DISEASES   OF   THE   URETHRA. 

extousive  wounds  and  lacerations  of  the  canal  are  often  absolutely  in- 
nocuous, and  that,  too,  where  the  urine  is  strongly  alkaline,  even 
ammoniacal.  Gosselin,  while  patriotically  adhering  to  the  "  absorption 
urineuse  "  theory,  inclines  to  a  belief  that  the  absorption  of  the  bacteria 
of  decomposing  urine  may  have  something  to  do  with  the  deadly  result, 
as  well  as  the  absorption  of  carbonate  of  ammonia,  to  which  he  ascribes 
a  large  share  of  inlluence. 

The  position  of  the  injury  inflicted  by  the  instrument  is  of  impor- 
tance. At  and  near  the  meatus  even  serious  injuries  very  rarely  give 
rise  to  chill,  though  decom2)osed  urine  pass  freely  over  the  raw  surface. 
The  danger  increases  in  proportion  to  the  depth  at  which  the  injury 
is  inflicted.  Nor  does  a  wound  seem  to  be  necessary  at  all,  since  cases 
are  on  record  where  death,  following  rajiidly  u])on  the  introduction  of 
a  smooth  instrument,  has  failed  to  reveal  on  autopsy  any  lesion  of  the 
canal.  Here  shock  and  reflex  action  (Banks)  arresting  kidney  secre- 
tion would  seem  to  be  the  immediate  cause  of  death.  The  chill  may 
come  on  before  the  instrument  used  has  been  withdrawn  from  the 
urethra,  but  usually  it  does  not  follow  for  some  hours,  and  generally 
not  until  after  urine  has  flowed  through  the  canal.  In  the  rapidly  fatal 
cases,  old  and  often  advanced  kidney  disease,  or  at  least  intense  kidney 
hyperaemia,  is  found  on  autopsy  ;  but  in  some  cases  these  organs  have 
been  j^ronounced  normal.  Morris  believes  the  kidney  to  be  always 
pathologically  the  cause  of  the  symptoms  of  urethral  fever,  the  lesions 
varying  from  congestion  through  interstitial  nephritis  to  abscess.  He 
strongly  advocates  the  nervous  reflex  theory  in  all  cases.  Even  in 
these  latter  there  has  usually  been  suppression  of  urine  ;  but  simple 
suppression  of  urine  does  not  often  kill  in  one  or  two  days,  and,  to 
solve  the  problem  in  these  cases,  we  are  forced  to  fall  back  upon  the 
effects  of  shock. 

Treatment. — The  treatment  of  urethral  fever  is  mainly  prophylac- 
tic. The  object  is  to  avoid  chill ;  for,  after  the  latter  has  occurred, 
but  little  can  be  done  to  modify  the  paroxysm.  I  do  not  know  any 
remedy  that  can  avert  chill  in  all  cases,  but  I  place  more  reliance  upon 
a  combination  of  pilocarj)ine  and  morphine  than  on  anything  else.  I 
have  seen  more  than  one  case  where  chill  necessarily  followed  ordinary 
urethral  instrumentation,  and  have  averted  the  chill  witii  the  same 
instrumentation  by  the  subcutaneous  use  of  from  a  fifth  to  a  tenth 
of  a  grain  of  muriate  or  nitrate  of  pilocarpine  given  subcutaneously 
with  five  or  ten  minims  of  Magendie's  solution  just  before  or  after  the 
operation.  I  have  also  often  seen  this  means  fail,  and  therefore  only 
suggest  it,  not  as  a  cure,  but  as  the  best  treatment  I  know. 

The  very  best  prophylactic  treatment,  perhaps,  is  a  jirolonged  milk- 
diet  and  the  use  of  benzoic  acid  in  five-  to  fifteen-grain  doses  in  cap- 
sule, or  of  larger  doses  of  the  bcnzoatc  of  soda,  Avhich  is  better  borne 
in  all  cases  where  the  urine  is  ammoniacal — especially  if  it  is  also 


URETHRAL   OR   URINARY   FEVER.  51 

slightly  putrid.  But  when  the  urine  is  normal  these  precautions  arc 
unnecessary. 

Quinine  is  generally  given  both  before  and  during  urethral  fever — 
but  I  find  myself  each  year  attaching  less  and  less  importance  to  it 
either  as  prophylactic  or  curative  in  urethral  fever.  Still,  it  can  do 
no  harm,  and  I  do  not  wish  to  condemn  it  from  an  impression,  which 
may  be  faulty.  Quiet  and  rest  in  bed  for  some  hours — perhaps  a  day 
or  more — before  an  operation  have  a  good  influence,  and  a  Avarm  bath 
just  before  an  operation,  I  believe,  is  not  without  advantage.  I  have 
ceased  to  believe  that  anassthesia  at  an  operation  materially  lessens  the 
chance  of  chill,  nor  do  I  believe  that  the  local  use  of  a  solution  of  the 
hydrochlorate  of  cocaine  has  any  good  effect  in  this  direction.  I  am 
also  beginning  to  have  more  faith  in  the  efiBcacy  of  tying  in  a  cathe- 
ter— a  large,  soft,  rubber  one — after  urethral  operations  which  involve 
portions  deeper  than  the  anterior  fold  of  the  triangular  ligament.  In 
front  of  this  point  I  think  it  unnecessary,  because  what  urethral  fever 
comes  from  operations  on  the  anterior  urethra  is  usually  slight.  After 
perineal  section  and  tying  in  a  tube,  and  after  lithotomy  operations  in 
the  perinasum,  urethral  fever  is  the  exception. 

If  the  attack  is  a  rapidly  pernicious  one,  morphine,  hot-air  baths 
and  stimulants,  cups  to  the  loins — and  a  bad  prognosis — constitute  the 
treatment.  If  surgical  kidney  or  pyeemia  are  ushered  in  by  chill,  they 
must  be  treated  generally  on  their  symptoms ;  but  a  milk-diet,  per- 
haps a  little  quinine,  and  mild,  sometimes  heavy  stimulation,  consti- 
tute our  most  hopeful  weapons  of  attack  in  these  serious  conditions. 
The  suggestions  of  Gouley  *  and  Long  f  as  to  the  prophylactic  value 
of  the  tincture  of  the  chloride  of  iron  and  of  two-minim  doses  of 
Fleming's  tincture  of  aconite  I  can  not  indorse  by  any  personally  fa- 
vorable experience. 

The  peculiarities  of  this  fever  are  well  known.  The  profession  is 
familiar  with  Thompson's  case,  J  where  a  man  with  old,  tight  stricture 
died  on  the  third  day  after  the  passage  of  an  instrument,  luliich  liad 
heen  used  upon  Mm  very  many  times  before.  Vomiting  with  severe 
chill  came  on  in  an  hour — immediate  suppression  and  death  followed. 
Autopsy  failed  to  reveal  any  lesion  of  the  urethra  caused  by  the  instru- 
ment.    The  kidneys  were  intensely  congested  and  soft. 

Among  Velpeau's*  cases — which  have  become  classical — no  kid- 
ney lesions  were  found  in  several  patients  who  died  in  this  sudden 
manner ;  and  hardly  a  year  goes  by  that  the  medical  journals  do  not 
furnish  reports  of  further  victims  to  urethral  fever,  some  without,  but 
the  majority  with,  kidney  disease. 

*  "Diseases  of  the  Urinary  Organs,"  1S73. 

f  "Liverpool  Med.-Chir.  Jour.,"  January,  1858. 

:j:  "  Stricture  of  the  Urethra,"  third  edition,  London,  p.  94. 

*  "Le9ons  orales  d.  Clin.  Chir.,"  etc.,  Paris,  1841,  p.  326. 


52  DISEASES   OF   THE   TRETIIRA. 

I  have  had  a  number  of  cases  wlicre  the  passage  of  any  instrument 
effecting  even  very  moderate  dihitation  icifhout  brimjing  Hood  would 
be  followed  by  cliill,  and  yet  divulsion,  tearing  the  urethra,  and  opening 
the  fixsucs  freely,  did  not  occasion  the  customary  chill  and  fever.  In 
short,  there  are  so  many  exceptions  that  a  rule  can  not  be  safely  for- 
mulated ;  but,  in  a  general  way,  it  may  be  said  that  the  greater  the 
violence,  the  deeper  in  the  urethra  that  the  violence  is  a])plied  (but 
I  must  except  cases  of  perineal  external  incision),  the  more  ])utrid  and 
ammoniacal  the  urine,  and  the  more  damaged  (in  a  surgical,  pyelitic 
way)  the  kidneys,  the  greater  the  liability  to  urethral  fever,  and,  if  it 
comes,  the  more  likely  is  it  to  be  grave. 

FOREIGN    BODIES    IN    THE    URETHRA. 

The  most  varied  substances  are  found  in  the  urethra,*  introduced 
by  the  patient  under  the  influence  of  that  perverted  and  depraved 
sexual  instinct  which  affects  the  male  of  all  ages  who  gives  up  his 
mind  to  impure  thoughts  and  whose  sexual  necessities  are  not  met. 

Seeds,  stones,  beads,  beans,  peas,  nails,  pins,  needles,  hair-pins, 
slate-pencils,  portions  of  glass,  wax,  cork,  and  a  host  of  other  sub- 
stances, are  thus  introduced  into  the  meatus,  and,  slipping  beyond  the 
reach  of  the  fingers,  are  not  unfrequently  swallowed  by  the  urethra. 
Broken  catheters  and  bougies,  esi^ecially  in  cases  of  stricture,  and  in- 
struments left  a  demeure,  if  not  well  fastened,  may  slip  past  the  me- 
atus and  travel  toward  the  bladder.  Fragments  of  stone  after  crush- 
ing, or  small  stones,  may  also  become  arrested  in  the  ui-ethra  and 
demand  the  surgeon's  aid.  Then,  again,  stone  may  form  in  the  pros- 
tate, or  in  the  urethra  behind  a  stricture,  or  ui^on  a  nucleus — some 
small  foreign  body  introduced  from  without ;  foreign  bodies  from 
dermoid  cysts,  or  passing  through  fistula  in  the  rectum,  may  reach  the 
urethra  and  become  arrested  there.  Long  bodies  always  tend  to  travel 
toward  the  bladder,  especially  if  they  are  sharp  at  one  end  (pins),  as 
such  bodies  are  always  introduced  blunt-end  foremost.  Stones  and 
rounded  bodies  lie  in  the  naturally  wider  parts  of  the  canal  (fossa  na- 
vicularis,  bulbous  urethra),  or  become  arrested  by  stricture. 

If  foreign  bodies  are  not  removed,  one  of  three  consequences  fol- 
lows :  1.  They  travel  on  into  the  bladder  and  form  a  nucleus  for  stone 
there ;  or,  2.  Stone  forms  around  them  in  the  urethra ;  or,  3.  They 
cause  the  urethra  to  inflame,  bring  on  retention  of  urine,  and  finally 
become  encysted  or  ulcerate  their  way  out,  leaving  behind  fistula  and 
ultimately  stricture. 

Treatment. — If  the  body  be  long  and  soft  (catheter,  piece  of 
wood),  it  may  be  transfixed  with  a  stout  needle  through  the  floor  of 

*  Consult  Poulct  on  "Foreign  Bodies."  Translation.  William  Wood  &  Co.,  New 
York,  1880,  p   110. 


FOREIGN   BODIES   IN   THE   UiiETIIRA.  53 

the  urethra  and  the  canal  pushed  back  over  it,  like  a  glove  over  a  fin- 
ger, as  far  as  possible,  when  it  may  be  transfixed  again,  and  ho  urged 
forward  until  it  reaches  the  meatus  ;  otherwise,  the  long  urethral  foi'- 
ceps,  the  alligator  forceps,  the  ingenious  scoop  of  Leroy  d'Etiolle  for 
small  round  bodies,  or  the  urethral  lithotrite  may  be  used.  I  have 
employed*  for  this  purpose  successfully  the  ordinary  Thompson 
stricture  divulsor,  opening  it  after  passing  the  foreign  body,  and, 
on  closing  the  instrument,  finding  the  latter  between  the  blades.  In 
manipulating  with  any  ordinary  forceps,  if  the  finger  on  the  outside 
can  detect  the  foreign  body  and  can  get  behind  it,  nothing  should 
divert  the  surgeon  from  keeping  up  pressure  at  that  point  to  j)revent 
his  instrument  from  pushing  the  offending  substance  still  deeper  into 
the  canal. 

If  the  foreign  body  lies  behind  a  stricture,  the  latter  must  be  cut, 
divulsed,  or  rapidly  dilated  (continuous  dilatation),  to  allow  the  pass- 
age of  a  suitable  instrument  for  extraction. 

Pins  and  needles  usually  necessitate  an  opening  of  the  urethra 
from  the  outside.  Such  an  opening  should  never  be  made  through 
the  scrotum,  for  fear  of  infiltration.  It  is  preferable  to  cut  through 
the  perinseum,  even  if  the  foreign  body  has  to  be  pushed  back  in  order 
to  be  caught.  The  urethra  may  be  opened  by  cutting  upon  the  for- 
eign body,  or  upon  the  end  of  a  staff  in  the  urethra  pushed  up  to  it. 
The  after-treatment  of  wounds  so  made  is  the  same  as  for  incised 
wounds  of  the  urethra.  The  incisions  should  invariably  be  longitudi- 
nal. Dieffenbach  removed  a  pin  very  adroitly  from  the  membranous 
urethra,  by  introducing  a  finger  into  the  rectum,  pushing  upon  its 
head  until  the  point  had  been  caused  to  penetrate  the  skin,  and  then 
seizing  and  forcibly  extracting  it.  I  extracted  one  with  Thompson's 
divulsor. 

Polyin  and  Warts. — Polypi  are  occasionally  found  in  the  urethra, 
several  of  them  at  a  time,  or,  more  often,  one  alone.  They  are  usu- 
ally attached  to  the  floor  of  the  canal,  habitually  in  the  anterior  part 
of  the  urethra.  They  are  generally  soft,  gelatiniform,  but  sometimes 
fibro-cellular,  of  greater  firmness.  At  an  autopsy,  Thompson  f  found 
one  five-eighths  of  an  inch  long,  attached  to  the  summit  of  the  veru 
montanum,  a  very  rare  situation.  Urethral  polypi  are  usually  small,  but 
sometimes  large  enough  to  obstruct  the  free  outflow  of  urine  and  occa- 
sion some  muco-purulent  discharge.  When  pedunculated,  they  may 
be  removed  (if  detected  in  the  anterior  urethra)  by  being  snared  with 
a  wire  loop  ;  when  deeply  seated,  they  must  be  torn  away  with  forceps. 
Demarquay  %  has  collected  some  interesting  cases.  Ordinary  venereal 
warts  sometimes  grow  within  the  urethral  orifice,  and  are  difficult  to 
dispose  of,  particularly  if  deeply  seated  in  the  canal.     I  have  seen 

*  "New  York  Medical  Record,"  March  6  and  May  1,  1SY5. 

f  London  "Lancet,"  March  15,  1856,  p   288.  %  Op.  cit,  p.  333. 


54  DISEASES   OF   THE   URETHRA. 

tbeni  tlu-ough  the  eudoscope  several  inches  doAvn  the  urethra.  They 
yield  an  annoying,  thin,  purulent  discharge.  Their  treatnaent  is  cau- 
terization through  tiie  endoscopic  tube,*  bismuth  injections,  and  in- 
ternally the, tincture  of  thuja  occidcntalis  u])  to  one-drachm  doses. 
"Warts  near  the  meatus  may  be  cut  or  scraped  away,  and  the  base  from 
■which  thcv  jrrow  cauterized. 


CHAPTER  III. 

DISEASES  OF  THE  URETHRA. 

Inflammation.— Causes. — Subdivisions  :  Gonorrhcra  ;  Bastard  Gonorrhnea  ;  Urethritis. — Sj-mptoms. 
— Duration.— Course.— Gleet.— Complications  of  Urethral  Inflammation. — Treatment ;  Method 
of  performing  Injection  ;  Abortive  Treatment.— ^Methodic  Treatment  of  Increasing  Stage,  in- 
cluding Description  of  Wrappings  ;  of  Stationary  Stage,  including  Chordee  ;  of  Decreasing 
Stage,  including  Copaibal  Erythema. — Gleety  Stage  ;  Treatment  of  Gleet.— The  Endoscope. — 
Rare  Sequelae  of  Gonorrhoea. 

Gonorrhoea — Urethritis. — Of  all  the  diseases  encountered  in 
genito-urinary  surgery,  urethral  inflammation  is  the  most  common. 
Furthermore,  although  a  strictly  local  affection,  and  exerting  no  poi- 
sonous action  upon  the  blood,  it  is  the  most  yenereal  of  all  venereal 
diseases,  since  it  is  tlie  commonest  malady  acquired  during  the  copu- 
lative act.  A  most  respectable  antiquity  is  given  to  the  disease  by  the 
fifteenth  chajiter  of  Leviticus,  and,  although  it  is  contended  that  the 
discharge  known  to  the  Jewish  lawgiver  was  a  simple  urethritis,  and 
that  gonorrhoea  (a  specific  infection)  did  not  appear  until  later  (ac- 
cording to  Astruc,f  in  the  year  1545-'46),  yet  the  disease  was  evi- 
dently a  running  from  the  urethra,  and  discussions  about  its  simple 
or  specific  nature  belong  to  theoretical  and  not  to  practical  text-books. 
We  have  to  start  from  the  clinical  facts  that  all  inflammations  of  the 
urethra  are  characterized  by  the  discharge  of  pus,  or  muco-pus,  from 
the  meatus,  and  that  the  best  guide  for  treatment  is  the  amount  of 
the  inflammation,  and  the  quantity  and  quality  of  the  discharge  J — an 
inflammation  of  given  intensity  requiring  a  given  treatment,  whether 
it  has  sprung  from  specific  contagion  or  from  chemical  or  mechanical 
irritation.  This  point  makes  it  necessary  to  study  both  maladies, 
clinically,  under  the  same  head.  That  there  are  two  maladies,  one 
virulent  and  one  simple,  is  and  always  has  been  certain  ;  the  difficulty 
has  been  to  distinguish  between  them,  for  their  symptoms  are  nearly 
identical.     Modern  science  is  endeavoring  to  solve  the  problem,  and 

*  Belfield,  "  Diseases  of  the  Urinary  and  Male  Sexual  Organs,"  New  York,  1884,  p.  69. 
f  "De  Morbis  Venereis,"  Paris,  1736. 

X  "  Dry  gonorrhcra  "  is  an  impossibility.     The  morbid  state  formerly  known  by  that 
name  is  neuralgia  of  the  urethra. 


URETIIKAL   INFLAMMATION— CAUSES.  55 

the  gonococcus  of  Neisser*  is  constantly  arrogating  to  itself  now 
claims  as  the  active  virulent  cause  of  true  specific  gonorrhoea. 

The  term  gonorrhoea  is  ctymologically  inaccurate,  indicating,  as  it 
does,  a  flow  of  semen  (yovos)  ;  but  usage  has  secured  to  it  a  precise 
signification  even  among  the  laity  (almost  to  the  exclusion  of  the  old 
Saxon  term  dap),  and  any  alteration  would  lead  to  confusion.  Ure- 
thritis signifies  simply  inflammation  of  the  urethra,  consequently  gon- 
ovrlacBa  is  urethritis,  but  the  converse  does  not  hold  good  ;  and,  al- 
though without  the  microscope  it  is  impossible,  in  a  condition  of  high 
urethral  inflammation,  to  pronounce  upon  its  origin  with  certainty, 
yet  it  is  better  for  practical  purposes  to  retain  the  two  terms,  calling 
that  gonorrhoea  which  has  been  derived  unmistakably  from  an  indi- 
vidual of  the  other  sex  with  a  gonorrhoea,  and  reserving  the  term  ure- 
thritis for  all  inflammatory  urethral  discharges  having  another  origin, 
and  for  all  cases  of  doubt.  This  latter  precaution  is  of  the  utmost 
importance  to  the  student  and  young  practitioner.  It  is  better  that 
a  hundred  of  the  guilty  should  escape  than  that  one  innocent  person 
should  be  accused.  Experience  proves  beyond  a  doubt  that  a  high 
condition  of  urethral  inflammation  attended  by  an  abundant  dis- 
charge, and  presenting  absolutely  no  diagnostic  features  to  differen- 
tiate it  from  a  gonorrhoea  unless  the  microscope  solves  the  doubt — 
that  such  a  urethral  inflammation  may  be  acquired  by  a  healthy 
young  lover  from  his  equally  healthy  mistress,  by  a  young  husband 
from  his  wife,  or  may  be  produced  by  applying  a  chemical  irritant  to 
the  urethra.  These  cases  are  doubtless  rare,  but  are  of  undoubted 
authenticity,  and  it  becomes  the  surgeon's  duty  to  hesitate  long  before 
asserting  the  infidelity  of  a  man  or  woman,  and  thus,  perhaps,  accus- 
ing the  innocent  and  destroying  the  harmony  of  a  family.  It  is 
proper  to  state  that  a  healthy  man  may  get  a  urethritis  from  a  woman 
who  has  none  (may  give  himself  the  gonorrhoea,  as  Ricord  puts  it)  far 
more  easily  than  a  woman  can  get  a  discharge  from  a  healthy  man, 
unless,  of  course,  great  mechanical  violence  be  used,  as  in  rape. 

Causes  of  Urethral  IxFLAiiMATiox. — Gonorrhoea  is  a  notori- 
ously contagious  disease,  and  it  may  be  acquired,  from  any  person 
having  it,  by  the  mere  contact  of  the  discharge  with  the  mucous 
membrane  of  the  urethra,  f      It  is  not  necessary  that  the  surface 

*  "Cntrlbltt.  f.  Med.,"  No.  28,  ISTO,  p.  497. 

I  The  only  mucous  (or  other,  as  far  as  known)  membranes  of  the  body  capable  of  tak- 
ing on  inflammation  from  the  contact  of  gonorrhoea!  pus  are  the  urethral,  vesical,  by  ex- 
tension (gonon-hoeal  cystitis),  the  vaginal  (the  uterine  and  tubal  by  extension),  the  con- 
junctival, and  the  rectal.  Buccal,  aural,  nasal,  and  umbilical  gonorrhoea  have  been  men- 
tioned, but  authors  are  of  accord  that  the  cases  cited  are  not  conclusively  proved.  Gon- 
orrhoea of  the  rectum  has  undoubtedly  been  observed  in  several  instances ;  one  case  by 
Tardieu  ("  Etudes  medico-legales  sur  les  Attentats  k  la  Pudeur,"  p.  180)  in  a  prostitute 
who  had  practiced  sodomy ;  and  three  cases  by  Allingham  ("  Diseases  of  the  Rectum," 
London,  ISYl,  p.  23'7),  all  in  prostitutes,  "who  all  confessed  the  manner  in  which  they 


56  DISEASES   OF  TUE   URETHRA. 

slioiild  be  abraded.  Simple  contact  is  euougli  without  any  sexual  act, 
as  has  been  abundantly  proved  by  the  experiments  of  B.  Bell,  Baumes, 
Eodet,  and  others.* 

Tl»e  discussion  upon  even  tiie  existence  of  a  virulent  gonorrliOBa 
has  been  active  of  late  years.  Ricord  did  not  believe  strictly  in  it, 
thinking  that  one  could  give  himself  a  gonorrhoea.  Bumstead  decided 
against  it,  the  German  school  declared  the  inflammation  to  possess  no 
virus  sid  generis,  and  matters  were  rapidly  reaching  a  position  that 
would  make  the  assumption  of  any  ditfercnce  between  gonorrhoea  and 
urethritis  untenable  f  when  Neisser's  announcement  appeared  claiming 
that  he  had  discovered  the  essential  causative  clement  of  gonorrhoea 
to  be  a  peculiar  vegetable  parasite  which  he  likened  to  sarciua  and 
christened  gojiococciis.  This  announcement  naturally  challenged  con- 
troversy, and  there  has  been  no  stint  of  investigation.  J  Pure  cultures 
of  the  vegetable  organism  have  been  difficult  to  obtain,  and  much  con- 
fusion in  the  long  discussion  to  which  this  question  has  given  rise  is 
due  to  the  fact  that  there  is  another  coccus,,  much  like  the  gonococcus, 
which  may  be  found  normally  in  the  urethra  (urethrococcus)  ;  and 
indeed  a  similar  black  set  of  spots  may  be  found  in  the  normal  secre- 
tions of  other  membranes  (mouth)  and  even  in  the  pus  of  an  acute 
abscess.  The  difference,  however,  appears  to  be  this,  that  while  a  single 
coccus  is  only  a  black  minute  dot,  and  this  dot  is  about  the  same  in 
appearance  and  under  staining  whether  the  coccus  be  a  gonococcus, 

got  so  affected."  Gosselin  also  saw  a  case,  "  Retrecissements  syphilitiqucs  du  rectum," 
"Arch.  Gen.  de  Med.,"  1854,  vol.  ii,  p.  066.  R.  Winslow  reports  an  epidemic  of  rectal 
gonorrhoea  arising  from  sodomy  in  a  juvenile  asylum  near  Baltimore,  "  Medical  News," 
August  14,  1886.  Rollet  reports  a  case,  "Diet.  Encyc.  des  Sci.  Med.,"  art.  "Rectum." 
The  subject  has  been  investigated  by  Boniere,  "Arch.  Gen.  de  Med.,"  April,  1874;  Re- 
quin,  "  Elements  de  Path.  Med.,"  tome  i,  p.  Y29.  Tliiry  has  a  case,  "  Presse  Med.  Beige," 
No.  34,  1882,  p.  201. 

*  Rollet,  "Traits  des  Maladies  ven6riennes,"  Paris,  1864,  pp.  211,  el  scg. 

•)•  See  an  excellent  paper  by  Morrow,  "  New  York  Medical  Journal,"  September,  1881, 
p.  263. 

X  Among  the  able  articles  may  be  instanced :  A.  Neisser,  "  Ueber  eine  der  Gonorrhea 
eigenthiimliche  Mikrococcusform,"  "  Cntrlbltt.  f.  d.  medicin.  Wissenschaften,"  No.  28, 
IS'ZQ.  A.  Bokai,  "  Ueber  das  Contagium  der  acuten  Blennorrhoea,"  "  AUgem.  med. 
Centralzeitung,"  No.  74,  1880.  A.  Neisser,  "  Die  Mikrococcen  der  Gonorrhoea,"  "  Deutsche 
med.  Wochenschrift,"  1882,  p.  279.  M.  Bockhart,  "  Beitrag  zur  Actiologie  und  Patho- 
logic des  Ilamrohrcn-Trippers,"  "  Vicrtcljahrschrift  f.  Derm.  u.  Syph.,"  1883,  p.  3.  E. 
Welander,  "  Quelques  recherches  sur  les  microbes  pathogenes  de  la  Blennorrhagie,"  "  Gaz. 
Med.,"  1884,  p.  267,  and  "  Nord.  med.  Arkiv.,"  Bd.  xvi,  No.  2.  Ernst  Bumm,  "Der 
Mikroorganismus  der  gonorrhoischen  Schleimhaut-Erkrankungcn,"  Wiesbaden,  1885.  An- 
toinc  Magnin  and  George  M.  Sternberg,  "  Bacteria,"  New  York,  William  Wood  &  Co., 
1884.  Bockhart,  "  Monatsschrift  f.  pract.  Dermatologie,"  1886,  No.  4.  These  arc  among 
the  best  of  the  earlier  contributions  to  the  subject.  Many  others  have  appeared  and  are 
still  appearing.  George  E.  Brewer  has  very  ably  summarized  the  subject  in  an  article, 
"  The  Modem  Treatment  of  Urethritis,"  in  the  "  Journal  of  Cutaneous  and  Genito-Uri- 
nary  Diseases,"  May,  1887,  p.  170. 


URETHRAL   INFLAMMATION— CAUSES.  57 

a  urethrococcns,  or  a  coccus  i'ouiul  with  any  indifToront  pus,  yot  the 
true  gonococci,  as  Neisscr  has  sliowii,  are  pociiliar  in  their  develop- 
ment, and  arrange  themselves  always  in  multiples  of  two  and  in  lines 
tending  to  be  parallel,  showing  their  growth  by  segmentation.  Thus 
a  scattered  set  of  dots  means  nothing,  but  dots  arranged  in  couples, 
in  fours,  and  in  parallel  sets  mean  the  specific  gonococcus.  Theoreti- 
cally this  distinction  seems  easy  to  make,  but  practically  it  is  sometimes 
quite  difficult  to  decide  whether  the  clusters  of  minute  dots  in  a  given 
field  of  pus  are  arranged  at  random  in  a  clump  or  paired  off,  yet  a 
little  careful  study  usually  decides  the  point,  and  the  more  one  exam- 
ines the  little  dots  the  more  clear  seems  to  be  the  difference.  An- 
other distinction  seems  to  be  that  the  true  gonococci  are  found  inside 
the  pus-cells — other  cocci  only  outside. 

Recently  Max  Bockhart  *  has  described  two  cocci  found  in  non- 
virulent  urethritis  as  special  varieties.  The  gonococcus  of  Neisser  is 
uniformly  found  in  the  pus  and  in  the  conjunctival  tissues  in  gonor- 
rhceal  ophthalmia.  The  specific  organism  has  also  been  found  in  the 
pus  taken  from  a  knee-joint  in  a  case  of  gonorrhoeal  arthropathy 
(Hall).f     Westermark  J  has  also  found  it  in  the  pus  of  a  pyosal^Dinx. 

The  little  black  dots  which  constitute  the  gonococcus  lie  within 
the  pus-cells  as  well  as  upon  them  and  in  the  fluid  surrounding  them. 
Single  points  have  no  value.  To  be  distinctive,  the  gonococcus  must 
be  arranged  in  the  specific  grouping  in  pairs  and  fours  and  in  linear 
groupings.  To  prepare  a  specimen  of  pus  for  examination,  a  good 
method  is  to  place  a  little  pus  on  a  cover-glass,  cover  this  with  another 
cover-glass,  and  after  pressing  the  two  together  slide  them  apart.  This 
leaves  each  covered  on  one  side  with  a  thin,  uniform  film  of  pus.  The 
cover-glass  is  now  to  be  passed  a  few  times  rapidly  through  the  flame 
of  a  spirit-lamp,  the  purulent  film  being  upward.  This  causes  the 
thin  film  to  adhere  to  the  glass.  Next,  the  dried  film  is  covered  with 
a  very  strong  watery  solution  of  methyl  violet.  This  is  to  be  after  a 
couple  of  minutes  poured  off,  and  the  purulent  film  gently  irrigated 
with  water  to  wash  away  the  excess  of  coloring  matter.  The  cover- 
glass  is  now  to  be  mounted  with  glycerin.  The  nuclei  of  the  cells 
are  seen  darkly  tinged  in  purple,  the  outlines  of  the  cells  and  their 
granular  contents  are  faintly  tinted,  while  the  groups  of  cocci  are  quite 
manifest  as  clusters  of  minute  black  dots  arranged  as  already  indicated 
above.  A  magnifying  power  of  about  five  hundred  diameters  is  ample 
for  a  ready  appreciation  of  the  gonococcus.  The  more  virulent  the 
case  and  the  thicker  the  pus,  the  more  abundant  and  characteristic  are 
the  groups  of  gonococci.  The  plant  persists  to  the  end  of  the  conta- 
gious stage  of  the  disease. 

*  "  Monatsschrift  f .  prakt.  Dermatol.,"  April,  1886. 

•)•  "  New  York  Medical  Record,"  March  20,  18S6,  p.  335. 

X  Referred  to  iu  "  New  York  Medical  Record,"  July  31,  1886,  p.  138. 


58  DISEASES  OF  THE   URETHRA. 

Theoretically,  then,  the  gonococcus  is  a  most  valuable  means  of 
diagnosing  virnlence  in  a  given  urethral  discharge ;  and  practically  so,  as 
well,  in  a  small  minority  of  cases.  I  have  frequently  examined  urethral 
discharges,  and  intensely  purulent  ones  at  that,  and,  failing  to  find  the 
gonococcus,  have  pronounced  the  source  of  alleged  contagion  to  be 
non-virulent,  and  the  patient  to  possess  a  discharge  which  he  could  not 
communicate  to  another,  and  have  not  yet  been  proved  to  be  Avrong. 

On  the  other  hand,  I  have  found  abundant  gonococci  possessing 
all  their  typical  qualities  in  patients  who  were  married  and  practicing 
sexual  intercourse  without  communicating  disease  to  their  wives.  I 
have  found  typical  gonococci  in  the  little  shreds  of  pus  Avhich  are 
washed  out  of  the  urethra  by  the  urine  in  some  cases  for  months  after 
all  discharge  has  ceased,  and  I  have  seen  such  patients  marry  and  their 
wives  escape  unharmed.  Yet  I  have  never  examined  a  thick,  purulent 
discharge,  -which  I  believed  for  other  reasons  to  be  virulent,  without 
finding  it  loaded  with  gonococci,  and  my  belief  is  that  this  organism 
is  the  contagious  element  in  the  discharge.  But  I  believe  also  that 
the  practical  application  of  this  test  leaves  something  to  be  desired, 
for,  while  all  contagious  discharges  unmistakably  contain  typical  gono- 
cocci, there  are  certainly  some  cases  in  which  the  organism  exists  and 
yet  where  intercourse  is  practiced  without  spreading  the  contagion. 
A  discharge  not  containing  gonococci  is  certainly  not  contagious,  and 
this  fact  is  one  of  great  practical  importance  and  a  xcrj  reliable  one. 
A  discharge  containing  gonococci,  however,  is  not  necessarily  conta- 
gious iri  a  virulent  way. 

But,  clinically,  a  purulent  discharge  from  the  urethra  is  a  given 
malady,  and  that  its  cause  is  sometimes  virulent  (gonococcus)  and 
sometimes  simijle  does  not  materially  alter  the  question  of  its  clinical 
management,  nor  interfere  with  the  clinical  study  of  the  question  of 
urethral  purulent  discharges  as  a  whole,  for,  unfortunately,  the  dis- 
covery that  gonorrhoea  is  of  vegetable  origin  does  not  at  once  furnish 
us  with  a  means  of  always  being  able  to  abort  the  disease.  Parasiti- 
cides are  well  enough  theoretically,  but,  practically,  gonorrhoea  is  still 
difficult  to  abort,  but,  apparently,  not  so  much  so  as  it  was  before 
Xeisser  made  his  brilliant  discovery. 

Attempts  have  been  made  to  differentiate  the  true  from  false  gon- 
ococci by  staining  and  again  decolorizing  the  micro-organisms. 
Roux  *  devised  such  a  method,  and  in  this  country  Charles  W.  Allen  f 
comments  upon  it  and  thinks  well  of  it.  I  have  tested  the  method 
and  find  that  it  does  not  give  me  satisfactory  results,  and  I  believe 
that  a  reliable  method  of  positively  differentiating  true  from  false 
gonococci  is  yet  to  be  found. 

*  "Le  Concours  Medical,"  November  13,  1886. 

f  "Practical  Observations  on  the  Gonococcus,"  "Journal  of  Cutaneous  and  Genito- 
urinary Diseases,"  March,  1887,  p.  81. 


URETURAL   INFLAMMATION— CAUSES.  59 

Besides  the  gonococcus,  then,  as  a  cause  for  uretliral  inflammation, 
we  have  other  agencies  acting  from  within  and  from  witliout,  capable 
of  producing  similar  if  not  identical  clinical  symptoms. 

A  priori  there  is  no  reason  why  the  influence  of  cold  should  not 
produce  a  catarrhal  discharge  from  the  mucous  membrane  of  the  ure- 
thra, just  as  well  as  from  that  of  the  other  mucous  expansions ;  but 
clinical  experience  teaches  that  this  is  the  rarest  of  all  causes,  if,  in- 
deed, it  exist  at  all  for  the  healthy  canal.  An  irritating  substance 
acting  locally  seems  to  be  essential  to  urethral  inflammation.  The 
only  exceptions  to  this  rule  are  those  cases  where  prostration  or  excess- 
ive fatigue  has  given  rise  to  a  discharge  in  broken-down  constitutions 
of  the  strumous  or  gouty  order,  where  prolonged  ungratified  venereal 
excitement  has  been  followed  by  actual  inflammation  of  the  canal,  as 
in  the  case  reported  by  Latour,  and  alluded  to  in  most  text-books,*  or 
where  some  inflammatory  trouble,  usually  affecting  other  parts,  has 
accidentally  appeared  in  the  urethra.  Some  author  has  reported  a 
case  of  ordinary  herpes  of  the  urethra  with  discharge  alternating  with 
herpes  of  the  thigh.  Bassereau  and  Bumstead  speak  of  cases  of  muco- 
purulent urethral  flow  coming  on  with  the  first  appearance,  or  with  a 
relapse  of  secondary  syphilitic  eruptions,  the  cause  of  which  was  the 
development  of  mucous  patches  upon  the  urethral  mucous  membrane. 
Ricord  f  details  a  case  of  tubercular  deposit  within  the  urethra  at- 
tended by  urethral  discharge.  A  patient  under  the  author's  care  with 
tertiary  syphilis  has  had  a  muco-purulent  discharge  on  several  occa- 
sions, depending  upon  the  development  of  a  tubercular  eruption  in 
the  urethra,  growing  sufficiently  to  occasion  obstruction  to  the  free 
escape  of  urine,  and  supplying  a  decided  discharge  ;  symptoms  always 
relieved,  and  the  caliber  of  the  urethra  restored,  by  the  internal  exhi- 
bition of  iodide  of  potassium.  Syphilitic  tubercles  around  the  orifice 
of  the  urethra  are  not  very  uncommon. 

Mechanical  Violence — sufficiently  intense  or  prolonged — will 
always  produce  urethritis  ;  but  in  these  cases  the  inflammation  is  usu- 
ally developed  in  proportion  to  the  extent  and  character  of  the  injury, 
and  tends  to  get  well  rapidly.  To  this  class  of  causes  belong  the 
rough  use  of  instruments  in  the  urethra,  instruments  left  a  demeure 
(tied  in),  violence  inflicted  by  foreign  bodies  introduced  from  with- 
out or  passing  from  the  bladder  (stone  fragments).  The  abundant 
formation  of  large  crystals  of  uric  acid  in  the  urine  acts  also  mechan- 
ically by  scratching,  but  usually  is  insufficient  to  cause  urethritis  in 
a  perfectly  healthy  subject.  As  a  rule,  urethritis  from  mechanical 
violence  commences  at  once,  and  tends  to  get  well  speedily,  if  the 
cause  does  not  continue  to  act. 

Chemical  Violence. — Irritants  acting  chemically  are  potent  for 
evil.     Under  this  head  come  strongly  concentrated  acid  urine ;  the 

*  Rollet,  op.  cit.,  p.  236.  \  "  Bull,  de  I'Acad.,"  Tol.  xv,  p.  565. 


60  DISEASES   OF   THE   UKETIIRA. 

action  of  certain  substances  ingested — cantliarides  ;  strongly  acid  or 
alkaline  injections  ;  rancid  or  acrid  iluids  or  secretions — leucorrluoal 
disci uirges,  lochia%  and  the  menstrual  How. 

Of  these  chemical  irritants  the  last  group  mentioned  deserves  spe- 
cial notice.  As  a  rule  alone  they  are  unable  to  cause  urethritis ; 
something  else  must  intensify  their  action  in  order  to  make  them 
ctfective,  and  that  something  is  eitiier  prolonged  and  excessive  sexual 
excitement  and  indulgence,  a  weakened  condition  induced  by  fatigue 
and  excitement,  an  impaired  state  of  urethra  coinciding  with  stricture 
or  left  behind  by  previous  attacks  of  intlammation,  or  individual  idio- 
syncrasy, or  coincidence  of  some  other  cause,  as  irritating  urine.  If 
this  were  not  the  case,  married  men  would  be  much  more  afflicted 
than  they  are,  for  few  women  (especially  in  large  cities)  are  free  from 
more  or  less  Icucorrho^a,  and  young  married  couples  are  very  apt  to 
disregard  the  beginning  and  the  end  of  the  menstrual  flow.  Viewing 
the  subject  from  this  stand-point,  it  becomes  easy  to  account  for  the 
fact  that  one  man  may  live  with  impunity  with  a  woman  having  a 
leucorrhoeal  flow,  while  another  who  attempts  to  share  her  favors 
(under  stronger  venereal  excitement)  immediately  acquires  a  dis- 
charge. The  "  acclimatation  "  of  Eicord  is  accounted  for  in  the  same 
way  ;  that  is,  where  a  man  in  his  earlier  and  more  amorous  approaches 
acquires  a  urethritis  from  a  woman  with  leucorrhoea,  but  afterward 
lives  with  her  unharmed,  although  her  discharge  may  continue  una- 
bated. Finally,  in  this  way  is  explained  Eicord's  celebrated  "receipt 
for  getting  a  gonorrlicea"  {"  recette  j^our  attra^Jcr  Ja  chcmde-jnsse"), 
which  consists  in  taking  a  young,  amorous,  pale,  blonde  girl  (prefer- 
ably with  a  leucorrhoea),  dining  with  her,  drinking  white  wine,  cham- 
pagne, coffee,  and  liquor  in  abundance,  dancing  with  her  vigorousl}'-, 
performing  the  sexual  act  as  frequently  as  possible  during  the  night, 
taking  a  prolonged  warm  bath  in  the  morning — and  a  "  j^recaution- 
ary"  injection.  Such  a  course  would  undoubtedly  be  effective,  espe- 
cially if  the  individual  testing  the  "receipt"  were  lymphatic,  with  a 
large  meatus  and  a  tight  prepuce,  or  had  a  slight  hypospadias ;  and 
especially  if  his  urethra  contained  patches  of  congestion  or  slight 
stricture  left  behind  by  old  attacks  of  inflammation. 

Before  passing  to  the  symptoms  of  inflammation  of  the  urethra,  it 
is  well  to  take  a  short,  comprehensive  view  of  the  three  most  common 
forms  of  urethral  flow  at  their  commencement  as  they  come  under  the 
surgeon's  notice.  They  are  given  below  in  the  inverse  order  of  their 
severity,  and  may  be  styled  urethritis,  bastard  gonorrhoea,  and  gonor- 
rhoea : 

TJeethritis. — Cases  like  the  following  are  not  very  uncommon. 
The  patient,  often  a  lymphatic  young  man,  perhaps  not  long  married, 
virgin  of  all  antecedent  venereal  disease,  finds,  on  the  first,  second,  or 
third  day  after  having  indulged  in  sexual  intercourse,  probably  to  ex- 


URETURAL   INFLAMMATION— SYMPTOJLS.  f)l 

cess  (possibly  also  after  unwonted  j^otations,  and  with  a  partner  having 
a  leucorrhosa),  a  slight,  uneasy  sensation  at  the  meatus,  a  littie  smarting, 
and  a  pearly  drop — or  possibly  the  lips  of  the  urethra  glued  together — 
in  the  morning.  Here  the  prognosis  is  usually  good.  The  inflamma- 
tion will  probably  not  run  high  or  last  long,  and  the  microscope  will 
not  be  able  to  detect  any  specific  gonococci.  A  diagnosis  of  urethritis 
may  be  made  with  certainty  here,  but,  nevertheless,  the  discharge  may 
become  profuse,  the  inflammation  run  high  and  continue  many  weeks, 
and  the  disease  thus  become  indistinguishable  from  gonorrha3a.  Such 
an  attack  may  be  acquired  from  any  irritating  discharge,  aided  by  idio- 
syncrasy, acid  urine,  excessive  excitement,  etc. 

Bastaed  Gonorehcea. — A  patient  comes  with  a  little  oozing  from 
the  meatus,  perhaps  with  no  itching  sensation,  nor  any  smarting  on 
urination  ;  but  he  says  that  he  has  had  ''  the  disease"  on  several  occa- 
sions previously,  and  he  is  terrified  at  this  sign  of  a  new  attack,  which 
he  believes  inevitable.  He  states  that  (perhaps  after  copious  libations 
of  ale,  beer,  or  champagne)  he  sinned  with  a  suspicious  party,  and  that 
while  examining  himself  on  the  following  morning — or  after  forty- 
eight  hours — he  discovered,  to  his  horror,  the  little  opaline  drop  at  the 
meatus,  and  he  comes  at  once  to  seek  relief.  This  is  by  far  the  most 
common  story.  Such  a  patient  has  a  damaged  urethra,  a  jiatch  of 
chronic  congestion  with  or  without  thickening  of  the  urethral  walls,  or 
perhaps  a  positive  stricture,  of  which  he  knows  nothing,  has  been  left 
behind  by  his  previous  attacks,  and.  he  has  irritated  this  surface  and 
given  himself  a  discharge,  when  the  woman  was,  in  all  probability, 
sound,  or  had,  at  best,  only  a  certain  amount  of  leucorrhoea.  This  is 
not  true  gonorrhoea  :  it  is  bastard.  A  little  alkali  internally,  rest,  and 
a  mild  injection,  followed  by  the  gentle  hnd  judicious  use  of  the  steel 
sound,  will  usually  soon  quiet  the  patient's  fears  and  overcome  the 
threatened  evil.     In  such  cases  always  examine  for  stricture  later  on. 

GoNOEEHGEA. — True  gonorrhoea  requires  no  idiosyncrasy,  no  ale  or 
champagne,  no  excess,  no  weakened  condition  of  the  urethra  for  its 
development,  but  simply  intercourse  with  a  female  having  a  gouor- 
rhoeal  discharge.  Here,  after  a  period  of  perfect  rest  lasting  from  three 
to  eight  days,  as  a  rule,  the  urethral  disturbance  commences,  and  runs 
the  given  course  of  virulent,  specific  gonorrhoea. 

Symptoms  of  Inflammatioist  of  the  Ueethea. — The  period  of 
incubation  or  hatching — that  period  which  elapses  between  the  suspi- 
cious contact  and  the  first  appearance  of  discharge — varies  from  a  few 
hours  (rarely  less  than  twenty-four)  to  fourteen  days  (rarely  more  than 
eight).  The  first  symptom  in  true  gonorrhoea  is  usually  noticed  on  the 
fifth  to  the  seventh  day.  It  may  be  stated  as  a  rule,  to  which  there 
are,  however,  numerous  exceptions,  that  the  shorter  the  period  of  in- 
cubation the  milder  will  be  the  succeeding  attack  ;  but  this  rule  does 
not  hold  after  the  seventh  day.     A  tickling,  teasing,  itchy  irritation 


62  DISEASES  OF  TUE  URETURA. 

is  first  felt  at  the  orifice  of  the  urethra.  Tlie  lips  of  the  meatus 
are  found  adherout,  or  a  slight,  bluish,  sticky  discharge  is  seen  be- 
tween them.  A  slight  stinging  is  felt  on  urination.  The  lips  of  the 
meatus  now-  swell  a  little  and  become  reddened.  The  quantity  of  dis- 
charge increases,  and  it  becomes  opaline.  Greater  pain  is  felt  in  pass- 
ing water.     The  meatus  feels  hot  and  sore. 

After  the  lifth  day  from  its  first  appearance  the  discharge  becomes 
much  more  copious.  It  gets  thick  and  purulent,  and  soon  acquires  a 
greenish  color  from  slight  admixture  with  blood,  which  latter  may  ap- 
pear in  little  streaks.  If,  during  erection,  the  mucous  membrane  be- 
comes cracked,  ha?morrhage  may  be  considerable.  Pain  is  now  felt  all 
along  the  pendulous  portion  of  the  urethra,  and  the  canal  is  sensitive 
to  pressure.  Irradiating  pains  may  be  complained  of  in  the  groins, 
testicles,  perinanim,  cord,  and  back.  Involuntary  seminal  discharges 
at  night  are  sometimes  brought  on  by  the  local  irritation,  and  such 
ejaculations  may  be  exceedingly  painful.  The  urethral  mucous  mem- 
brane becomes  thickened  by  the  inflammation,  and  the  stream  of  urine 
is  consequently  small,  forked,  or  dribbling.  Eetentiou  may  come  on, 
possibly  from  spasmodic  muscular  contraction,  or  by  extension  of  the 
inflammation  backward,  causing  sudden  congestion  of  the  prostate 
(Thompson) — a  condition  recognized  by  rectal  examination.  But  re- 
tention Avitli  gonorrhoea  is,  of  all  complications,  the  most  rare,  unless 
the  patient  continues  to  drink  hard,  or  has  already  a  rather  tight 
stricture  before  he  acquires  the  disease. 

As  the  inflammation  advances,  the  prejrace  may  become  oedematous 
(lymphitis),  occasioning  phimosis  or  parajDhimosis ;  or,  if  the  prepuce 
be  naturally  tight,  the  inflammation  may  extend  into  the  balano-prepu- 
tial  cavity  and  light  up  balanitis.  Erections,  also,  at  this  time  become 
painful,  threatening  chordee.  This  indicates  that  the  inflammation 
has  extended  beyond  the  free  surface  of  the  mucous  membrane,  and 
has  included  the  delicate  meshes  of  the  erectile  tissue  of  the  corpus 
spongiosum.  As  a  rule,  the  higher  the  grade  of  urethral  inflamma- 
tion, the  greater  liability  is  there  to  chordee.  In  actual  chordee  more 
or  less  of  the  areolar  structure  of  the  corpus  spongiosum  has  become 
obliterated  by  the  efEusion  of  plastic  lymph,  while  other  portions  lose 
their  distensibility.  This  condition  may  implicate  a  longer  or  shorter 
distance  along  the  urethra,  sometimes  nearly  the  whole  pendulous 
portion.  The  corpus  spongiosum  consequently  does  not  allow  com- 
plete distention  of  its  areolas,  and  hence  the  urethra  is  comparatively 
too  short  for  the  erect  corpora  cavernosa,  and  bends  the  penis  down- 
ward like  a  bow  during  erection,  the  urethra  being  the  chord  to  the 
bow.  If  the  corpora  cavernosa  should  become  inflamed  and  the  cor- 
pus spongiosum  escape,  the  arching  would  be  in  the  opposite  direc- 
tion. This  sometimes,  but  very  rarelv,  takes  place.  A  sort  of  spuri- 
ous chordee,  upward  or  lateral,  may  be  caused  by  inflammation  of  the 


URETHRAL   INFLAMMATION— SYMPTOMS.  63 

lymphatics  along  the  dorsum  or  side  of  the  penis.  In  chordcc,  great 
pain  is  felt  from  the  stretching  of  the  inflamed  erectile  tissue.  This 
pain  is  measurably  relieved  hy  bending  the  penis  so  as  to  increase  the 
bow,  and  in  this  way  to  slacken  the  string ;  and  it  passes  off  entirely 
as  erection  disappears.  Chordee  is  most  frequent  during  the  night  and 
toward  morning.  It  may  render  sleep  impossible.  The  point  of  great- 
est curvature  is  situated  anywhere  along  the  pendulous  urethra,  most 
frequently  near  the  glans — gland  arque  (Ricord).  The  pernicious 
practice  of  "  breaking  the  chordee,"  which  consists  in  roughly  straight- 
ening the  penis  when  erect,  gives  rise  to  a  haemorrhage  which  may 
become  excessive  and  be  the  starting-point  of  organic  stricture. 

After  the  disease  has  continued  at  its  height  for  from  one  to  three 
weeks  under  favorable  circumstances,  the  pain  on  urination,  which 
had  traveled  down  to  the  root  of  the  penis,  ceases,  the  discharge  be- 
comes more  watery,  chordee  infrequent.  The  discharge  diminishes 
down  to  a  drop  in  the  morning,  the  meatus  again  sticks  together,  and 
finally  even  this  ceases,  and  the  patient  is  well. 

During  all  this  local  inflammatory  disturbance  there  is  little  if  any 
constitutional  sympathy.  There  may  be  some  feverishness  for  a  time, 
or,  in  nervous  individuals,  a  real  or  fancied  feeling  of  prostration  during 
the  continuance  of  the  discharge. 

The  DuRATio]!«r  oe  Go]sroRRH(EA  is  variable.  A  well-managed  case 
lasts  from  three  to  six  weeks,  as  a  rule  ;  but  the  discharge  may  con- 
tinue for  months  or  even  years.  A  first  gonorrhoea  is  the  most  se- 
vere ;  but  it  is  also  the  most  certain  to  get  perfectly  well  if  carefully 
managed. 

Course  of  Gokorrhcea. — The  urethral  inflammation  commences 
at  the  meatus  and  travels  slowly  backward.  According  to  Desor- 
meaux,*  on  the  eighth  day  of  the  discharge,  the  anterior  half  of  the 
urethra  has  become  invaded,  its  surface  is  congested,  without  polish, 
and  covered  with  little  bare  spots,  like  those  seen  in  balanitis,  where 
the  epithelium  has  exfoliated.  There  is  no  ulceration.  When  the 
discharge  is  older,  the  lesions  are  identical,  but  deeper  seated.  The 
disease  tends  to  limit  itself  and  to  become  localized  at  the  bulb,  in  the 
fossa  navicular! s,  or  at  some  intermediate  point,  where  there  may  have 
been  much  chordee;  At  these  points  of  localization,  the  surface  is  of 
a  vinous  red,  the  polish  of  healthy  epithelium  is  absent,  and  there  are 
perhaps  a  few  granulations.  The  submucous  tissue  thickens,  impair- 
ing the  vascularization  of  the  part,  and  this  process  may  go  on  to  the 
formation  of  organic  stricture.  Where  the  disease  runs  this  course, 
instead  of  getting  well,  we  have  gleet. 

Gleet. — In  gleet,  whether  due  to  forming  stricture  or  not  (the 
former  condition  is  vastly  more  common),  a  certain  amount  of  sticky, 

*  "  De  I'Endoscope  et  de  ses  Applications  au  Diagnostic  et  au  Traiteaient  des  Affec- 
tions de  rUrethre  et  de  la  Vessie,"  Paris,  1S65. 


64  DISEASES  OF  THE  URETHRA. 

bluish  fluid — often  only  a  drop  at  the  meatus  in  the  morning — con- 
tinues to  be  secreted  after  gonorrhoea — from  altered  patches  of  the 
urethra — or  coming  from  the  stretched  and  congested  membrane  be- 
hind a  stricture. 

Gleet,  then,  is  a  s3'mptora  of  two  structural  lesions,  and  signifies 
that  there  are  patches  of  congestion  in  the  canal,  covered  or  not  by 
granulations,  or  that  stricture  exists,  and  that  the  discharge  comes 
from  behind  it.  Granulations,  analogous  to  those  seen  in  granular 
lids,  may  be  observed,  when  present,  through  a  urethral  tube,  as  may 
the  little  vegetations,  or  polypoid  growths,  which  sometimes  spring 
from  altered  patches  of  urethral  membrane.  Idiopatliic  gleet  may 
come  on  in  individuals  of  a  strumous  or  gouty  diathesis,  the  immedi- 
ate cause  being  a  broken-down  constitution  or  acid  urine.  Prostatic 
congestion  and  enlargement  are  also  liable  to  be  attended  by  a  slight 
gleet,  as  are  also  mucous  patches  in  the  urethra,  etc.  Of  these  varie- 
ties, the  strumous  urethritis,  like  other  manifestations  of  the  diathe- 
sis, is  usually  found  in  early  life,  while  gouty  gleet  belongs  more  par- 
ticularly to  middle  age.  An  explosion  of  gout  may  come  on  in  this 
way,  a  distinctly  purulent  urethritis  of  some  severity  appearing  sud- 
denly in  a  gouty  individual,  after  chilling  of  the  legs  or  excess  at 
table,  especially  in  regard  to  drink.  When  an  individual  with  a  gleet 
is  found  to  be  gout}',  whether  his  discharge  be  idiopathic  or  not, 
it  is  particularly  advisable  to  enforce  urethral  hygiene  and  general 
dietetics. 

Gleet  tends  to  last  iudetinitely,  but  is  often  so  very  slight  as  to 
be  ignored.  An  individual  so  aifected  is  a  ripe  subject  for  bastard 
gonorrhoea.  The  simple  congested  patches,  without  sensible  thicken- 
ing or  granulations,  which  furnish  the  gleety  discharge  after  an  ordi- 
nary gonorrhoea,  are  kept  from  getting  well  by  alcohol,  malt  liquors, 
sexual  excess,  fatigue,  violent  exercise,  anaemia,  gouty  or  strumous 
habit,  etc.  If  one  of  these  causes  for  the  continuance  of  a  discharge 
do  not  exist,  it  will  usually  get  well  of  itself,  or  certainly  with  the 
help  of  some  mild  injection,  or  after  a  few  introductions  of  the  sound. 
Gleet  is  contagious  when  purulent — the  more  copious  and  creamy  the 
discharge  the  greater  its  infecting  power,  but  only  if  it  contains 
gonococci. 

COMPLICATIO^rS  OF  URETHRAL  IlfFLAMMATIOX. — Of  the  COmphca- 

tions  of  gonorrhoea,  some  have  already  been  described  :  balanitis,  in- 
flammatory phimosis,  chordee,  jaossible  retention,  and  ha3morrhage. 
Others  will  receive  attention  when  considering  the  organs  they  affect 
— epididymitis,  orchitis,  inflammation  of  seminal  vesicles,  gonorrhoeal 
cystitis,  catarrhal  i)rostatitis,  prostatic  congestion,  prostatic  and  peri- 
prostatic abscess.  The  others  will  be  dealt  with  after  the  section  on 
treatment — folliculitis,  cowperitis,  suppurating  peri-urethritis,  lym- 
l^hangitis,  and  adenitis — all  being  extensions  of  inflammation  from  the 


URETnRAL  INFLAMMATION— TREATMENT. 


05 


urethral  mucous  membrane ;    finally  will   bo  considered  gonorrho;al 
rheumatism,  gonorrhceal  ophthalmia,  and  gonorrhoeal  conjunctivitis. 
Treatment  of  Urethral  Inflammation. — There  are  two  methods  of 
treating  inflammation  of  the  urethra  : 

1.  The  abortive — which  seeks  to  strangle  it  at  once. 

2.  The  methodic — a  treatment  based  upon  the  intensity  and  stage 
of  the  inflammation. 

Injection  of  the  urethra  is  a  proceeding  so  often  resorted  to,  both 
early  and  late,  in  inflammation  of  the  canal,  that  the  subject  of  treat- 
ment may  be  well  introduced  by  a  few  words  upon  a  proper  method 
of  performing  this  surgical  manoeuvre. 

First,  as  to  a  choice  of  instrument.  The  nozzle  of 
the  syringe  must  be  short,  for  fear  of  scratching  and 
irritating  the  already  inflamed  membrane,  and  must 
expand  suddenly,  so  as  to  be  adaptable  to  orifices  of  all 
sizes.  Any  syringe  more  or  less  like  the  one  shown  in 
Fig.  19  is  capable  of  enabling  an  injection  to  be  made 
without  wetting  the  patient  or  scratching  the  inside 
of  his  inflamed  urethra.  Such  a  syringe  should  hold 
between  three  and  four  drachms,  not  that  the  whole 
of  this  quantity  must  be  introduced  at  each  injection, 
but  because  that  amount  may  be  necessary  to  properly 
distend  the  urethra  in  many  instances. 

To  inject  elegantly,  the  patient  encircles  his  penis 
behind  the  corona  with  the  thumb  and  first  finger  of 
his  left  hand,  uncovering  the  glans  penis  in  part  or 
wholly.  In  the  right  hand  he  holds  the  syringe  be- 
tween his  thumb  and  last  three  fingers,  placing  the  to]3 
of  his  index-finger  within  the  ring.  He  now  inserts 
the  blunt  nozzle  into  the  flaring  meatus,  and,  pulling 
the  penis  forward  with  his  left  hand,  he  pushes  the 
blunt  nozzle  well  into  the  gaping  urethra,  and  at  the 
same  time  slowly  causes  the  piston  to  descend.  He  continues  this 
manoeuvre  until  a  positive  feeling  of  distention  in  the  deep  urethra 
warns  him  that  the  urethra  will  hold  no  more.  Then,  tightening  the 
encircling  grasp  of  the  left  hand,  he  removes  the  syringe  and  holds 
some  convenient  vessel  in  front  of  the  penis,  Now  relaxing  the  press- 
ure upon  the  urethra,  the  injected  fluid  spurts  out  without  soiling 
clothing  or  hands.  It  is  always  well  to  pass  urine  immediately  before 
using  an  injection,  that  the  canal  may  be  thus  freed  from  pus. 

Abortive  Treatment. — The  idea  of  aborting  gonorrhoea  by  the 
internal  use  of  balsams  has  been  abandoned.  The  old  idea  of  abortive 
treatment  was  to  irritate  the  urethra,  substituting  a  simple  for  a  poi- 
sonous inflammation.  The  modern  idea  is  by  hot  irrigation  to  soothe 
the  membrane  and  wash  out  the  poison,  or  by  antiseptic  or  autipara- 
5 


Fig.  19. 


66  DISEASES  OF  THE  URETHRA. 

sitic  drugs  to  destroy  the  gouococcus.  Nitrate  of  silver  and  chloride  of 
zinc,  formerly  in  great  rejnite,  are  no  longer  relied  npon,  and  this  is 
fortunate,  for  they  often  did  harm,  and  rarely,  if  ever,  any  good  in 
true  gonorrhani,  the  only  one  of  the  class  of  maladies  we  are  con- 
sidering really  worth  a  serious  effort  at  producing  its  abortion.  Iodo- 
form has  been  tested  and  abandoned,  and  the  present  favorites  are  jiro- 
longed  irrigation  and  varying  strengths  of  the  bichloride  of  mercury. 
If  the  abortive  treatment  is  to  be  tried  as  such,  it  should  be  used 
within  the  first  twenty-four  hours  of  the  commencement  of  an  attack. 
The  bichloride  of  mercury  in  solution  has  been  used  at  varying 
strengths  up  to  one  in  one  thousand — nearly  half  a  grain  to  the  oimce. 
This,  however,  is  not  capable  in  my  hands  of  aborting  gonorrhoea. 
Even  a  sixteenth  of  a  grain  in  the  ounce  often  produces  severe  pain, 
and  greatly  increases  the  grade  of  the  inflammation  in  a  fresh,  young 
case  of  true  gonorrhoea.  I  have  never,  with  the  bichloride  of  mercury, 
been  able  to  entirely  arrest  a  true  gonorrhoea  at  once  or  to  kill  the 
gonococcus — using  it  weak  or  strong,  at  long  or  short  intervals. 

The  irrigation  method  has  had  some  ardent  advocates.  There  are 
two  ways  of  using  it — one  deep,  the  other  superficial.  By  the  deep 
method  a  small,  soft  catheter  is  gently  inserted  uj)  to  the  hole  in  the  tri- 
angular ligament,  and  a  pint  or  more  of  very  hot  water  is  run  through 
the  urethra  one  or  more  times  a  day.  Sometimes  a  strong  astringent 
injection,  as  of  tannin,  is  used  once  a  day  after  the  injection.  This 
method  I  believe  to  be  dangerous  in  some  cases.  It  will  abort  urethri- 
tis and  bastard  gonorrhoea,  but  in  my  hands  it  has  always  failed  to 
modify  a  virulent  attack  in  any  way  except  to  aggravate  it,  and  I  have 
treated  a  number  of  cases  in  which  cystitis,  prostatic  congestion — even 
abscess — epididymitis,  etc.,  had  been  directly  caused  by  this  abortive 
method  of  deep  urethral  irrigation  early  in  an  attack  at  the  hands  of 
other  surgeons.  I  think  this  method  often  useful  in  old  cases  or  late  in 
an  attack — not  in  the  beginning.  Dr.  Holbrook  Curtis  and  Dr.  Brewer 
think  highly  of  it  in  the  early  stages,  and  have  advo- 
cated it  in  the  journals. 

The  method  by  anterior  irrigation  is  more  rational, 

since  the  virulence  of  the  malady  confines  itself  at  first 

to  the  anterior  segment  of  the  urethra.     This  method 

combines  irrigation  with  a  very  mild  antiseptic  action. 

Its  introduction   in   New  York  is  largely  due  to  Dr. 

Halstead  and  the  Roosevelt  Dispensary.     The  method  is 

simply  to  put  a  quart  of  tepid  or  hot  water,  at  a  strength 

Fig.  20.  of  half  a  gram  of  bichloride  of  mercury  in  twenty-two 

ounces  (about  1  in  20,000),  into  a  fountain  syringe,  the 

rubber  tube  of  which  is  armed  with  a  nozzle  of  glass  shaped  like  Fig. 

20.     This  blunt  nozzle  is  simply  crowded  into  the  urethra,  and  then 

the  fluid  is  allowed  to  flow.     Soon  the  canal  is  distended,  after  which 


URETHRAL  INFLAMMATION— TREATMENT. 


G7 


the  whole  quart  of  fluid  is  allowed  to  run  through  the  anterior  ure- 
thra by  slightly  letting  up  the  pressure  on  the  orifice  so  that  the  water 
shall  trickle  out  slowly  alongside  of  the  glass  noz- 
zle. L.  F.  Keifcr*  has  devised  a  hard-rubber 
nozzle  for  irrigation  (Fig.  21).  The  nozzle  is 
kept  crowded  into  the  meatus,  the  fluid  runs  in 
through  one  arm  and  out  at  the  other,  the  ure- 
thra being  kept  ballooned  out,  and  a  constant 
irrigation  being  kept  up  by  regulating  the  amount 
of  outflow  with  the  finger  over  the  orifice  of  out- 
flow in  the  arm  of  exit.  This  irrigation  is  re- 
peated three  times  a  day,  and  the  malady,  if 
treated  within  twenty-four  hours  of  the  beginning 
of  the  attack,  may  be  sometimes  aborted,  it  is  said. 
This  is  true  for  urethritis ;  if  the  gonorrhoea  is 
virulent,  it  can  nearly  always  be  moderated  in  violence  and  sometimes 
cured  in  the  second  week — at  the  earliest.  This  is  my  present  view  ; 
others  claim  better  results. 

Instead  of  the  fountain  syringe,  I  now  generally  get  the  patient  to 
use  for  himself  a  little  red  soft-rubber  irrigator  called  the  universal  in- 
jector (Fig.  22).  I  direct  the  patient  to  dissolve 
one  fifth  of  a  grain  of  bichloride  of  mercury  in 
eight  ounces  of  water  (or  to  make  the  solution 
even  much  weaker  if  this  strength  causes  pain), 
and  to  practice  irrigation  of  his  urethra  with  it 
in  the  manner  described  above  about  three  times 
a  day.  A  speedy  diminution  in  the  discharge 
often  follows,  but  not  invariably.  I  rely  upon 
it,  in  the  beginning  of  all  acute  attacks,  with 
growing  confidence. 

This  treatment,  even  if  it  fails,  has  yet  the 
enormous  advantage  that  it  can  not  j)ossibly  do 
harm,  and  that  stricture  can  not  be  caused  by  it,  a  statement  which 
could  not  be  made  of  the  old  abortive  treatment  by  strong  injections 
of  the  nitrate  of  silver. 

Methodic  Teeatment  oe  Ueetheal  Inflammatio^t. — This  is 
the  rational  treatment  for  all  forms  of  urethral  discharge,  whatever 
their  nature,  based  upon  the  quantity  and  quality  of  the  discharge  and 
the  grade  of  the  inflammatory  action. 

The  hygienic  part  of  the  treatment  is  of  the  utmost  importance. 
If  it  be  disregarded,  the  best-directed  efforts  may  fail  to  arrest  the 
discharge.  Many  cases  of  simple  urethritis  and  bastard  gonorrhoea 
require  little  else  than  the  hygienic  treatment.  The  hygiene  of  gon- 
orrhoea is  as  follows  : 


Fig.  22. 


"  Medical  Record,"  April  9, 1887. 


68  DISEASES  OF  THE  URETHRA. 

Absolute  continence  until  at  least  ten  days  after  the  entire  cessa- 
tion of  discharge,  and  avoidance  of  anything  liable  to  induce  sexual 
excitement — company  of  a  mistress,  exciting  books,  thoughts,  etc. 
No  alcoholic  stimulants  of  any  sort,  particularly  no  sweet  fermented 
wine  (champagne),  and,  above  all,  no  malt  liquor,  should  be  drunk 
during  the  treatment.     Physical  repose  is  desirable. 

Increasinij  Stafjv. — There  is  no  objection  to  trying  the  abortive 
treatment  by  anterior  mild  bichloride  irrigation  in  any  case  seen 
early  enough.  "Where  it  does  not  cure,  it  does  no  harm,  and  nothing 
of  any  greater  value  can  •well  be  done  at  this  time.  An  alkaline  medi- 
cine is  tiie  only  internal  one  required.  The  bicarbonate  of  soda  is 
often  used,  but  the  citrate  of  potash,  being  mildly  diuretic,  usually 
acts  better.  It  may  be  given  in  simple  watery  solution  or  variously 
flavored,  at  a  dose  of  gr.  x — xx,  to  be  taken  in  water,  preferably 
during  the  second  hour  after  each  meal.  Enough  to  make  and  hold 
the  urine  alkaline  is  all  that  is  required,  and  such  a  dose  should  be 
maintained  through  the  entire  treatment,  whatever  other  medicine 
may  be  used.  If  the  ardor  urinee  is  very  gi'cat,  and  the  alkali  alone  does 
not  control  it,  from  one  to  five  minims  of  the  fluid  extract  of  hyoscy- 
amus  may  be  added  to  each  dose  of  alkali.  Sirup  of  cinnamon  masks 
the  taste  of  this  drug  reasonably  well.  Occasionally  twenty-grain  doses 
of  the  bromide  of  potassium  will  moderate  the  ardor  urincB,  and  act  as 
an  alkali  better  than  the  citrate  with  hyoscyamus.  It  is  hardly  projier 
to  use  opiates  for  the  simple  burning  on  urination.  If  the  bicarbonate 
of  soda  or  potash  be  used  as  an  alkali,  a  convenient  form  of  adminis- 
tration is  in  the  shape  of  the  compressed  jDellets  novr  so  much  in 
fashion. 

Among  the  balsamic  preparations,  the  oil  of  sandal-wood  and  the 
balsam  of  copaiba  help  to  moderate  the  ardor  urinae  in  the  first  stage 
of  gonorrhoea,  and  positively  moderate  the  discharge  in  bastard  gonor- 
rhoea and  urethritis — while  the  cubeb  preparations  are  of  less  value  in 
my  opinion.  These  balsams  are  of  great  value  in  the  treatment  of 
catarrhal  troubles  of  the  urethra,  but  to  be  of  service  they  must  be 
digested  comfortably.  If  sandal-wood  oil  gives  a  man  such  a  pain 
over  his  kidneys  that  he  can  neither  exercise  nor  sleep,  and  if  copaiba 
so  upsets  his  stomach  that  he  is  constantly  nauseated  and  declines 
food — such  a  patient  is  not  suitable  for  the  administration  of  either  of 
these  drugs,  and  it  is  folly  to  push  them.  But,  if  he  digests  either  of 
them  reasonably  well,  either  of  them  will  help  him  materially,  in  all 
of  the  acute  and  many  of  the  sub-acute  and  chronic  forms  of  urethral 
discharge.  Both  these  substances  are  to  be  found  in  capsules,  lU  x  in 
each.  The  dose  to  commence  with  is  one  after  each  meal,  and  in- 
crease up  to  two  or  three  at  a  dose,  if  the  patient's  stomach  bears  the 
medicine  kindly  ;  otherwise,  it  is  better  not  to  push  the  drug.  Sandal- 
wood oil  may  be  taken  dropped  upon  a  lump  of  sugar.     The  less  fas- 


URETHRAL  INFLAMMATION— TREATMENT.  (39 

tidious  may  take  all  the  requisite  medicine  at  a  dose  in  combination, 
as  in  the  following  formula  : 

;^  PotassEe  citratis,  3  ij-vj. 

Bals.  copaibjB,  3  iij-vj. 

Extr.  £1.  hyoscyami,  .    .-  3  ss-ij. 

Syr.  acaciic,  §  jss. 

AqupQ  menth.  pip.,  q.  8.  ad  §  iij.     M. 
S.  Shake.     Tcaspoonful  in  water. 

This  is  easier  to  digest  than  the  old  "  Lafayette  mixture,"  and  the 
citrate  of  potash  is  aj)parently  better  than  the  niter  and  liquor  potas- 
S9e  of  that  compound.  This  mixture  may  be  largely  modified  by 
substituting  sandal- wood  oil  for  copaiba,  leaving  out  the  hyoscyamus 
when  not  required,  putting  in  bicarbonate  of  soda  for  the  citrate  of 
potash  if  the  diuretic  effect  is  not  desired,  and  substituting  winter- 
green  water  for  the  mint  water,  or  even  adding  liquorice,  according  to 
taste.  When  a  combination  is  found  that  suits  the  patient's  palate 
and  stomach  moderately  well,  it  may  be  persisted  in  during  all  the 
acuter  stages  of  the  malady,  moderating  the  dosage  of  the  various  in- 
gredients as  required.  Another  aid  to  easy  micturition  is  Milton's 
plan  of  immersing  the  penis  in  hot  water  before  and  during  the  act. 
Fournier  advises  a  similar  use  of  very  cold  water.  Hot  water  I  think 
better  than  cold  in  the  acute  stages.  Its  use  just  before  re- 
tiring has  some  power  in  preventing  erection  and  chordee  at 
night.  The  lorappings  about  the  penis  should  be  light.  A 
susj)ensory  bandage  with  penis-bag  attached  is  a  suitable  ap- 
paratus, some  absorbent  cotton  being  put  into  the  bottom  of 
the  penis-bag.  A  simple  wrap  when  the  discharge  is  free  is 
two  thicknesses  of  ordinary  water-closet  paper.  In  this  the 
penis  is  wrapped,  the  free  end  of  the  resulting  roll  being 
twisted  or  gummed.  This  retains  itself.  If  the  discharge 
is  light  and  the  prepuce  long,  a  piece  of  lint  or  absorbent 
cotton  spread  over  the  meatus  and  glans,  and  retained  on 
either  side  by  the  prepuce,  makes  the  best  dressing  to  pro- 
tect the  clothes.  Or,  if  the  preiouce  is  short,  it  may  be  re- 
tracted, and  the  glans  passed  through  a  hole  just  sufficient 
to  receive  it,  cut  in  the  center  of  a  large  piece  of  muslin. 
The  muslin  is  drawn  behind  the  corona.  Finally,  by  pull- 
ing forward  the  short  prepuce,  the  dressing  is  completed. 

When  injections  are  used  in  the  increasing  stage,  they 
should  be  very  mild  ones,  that  is,  when  the  irrigation  plan 
is  not  attempted.     I  have  derived  great  advantage  from  using      fig-  as. 
a  four-per-cent  solution  of  the  hydrochlorate  of  cocaine,  and 
causing  the  patient  to  inject  from  ten  to  fifteen  minims  of  it  several 
times  a  day — sometimes  before  each  urinary  act,  since  it  greatly  re- 
duces the  ardor  urinse.     A  dropper  with  a  long-drawn  point,  nicely 


70  DISEASES  OF  THE  URETHRA. 

rounded,  aud  a  rubber  cap  is  tlie  most  convenieut  iustriimcnt  for  in- 
sertion (Fig.  23).  The  solution  must  be  thrown  in  gently  and  retained 
by  com})ressing  the  meatus  fur  several  minutes.  In  this  way  the  con- 
gestion of  the  acute  stage  is  diminished,  the  discharge  reduced,  the 
pain  on  urination  mitigated  greatly,  and  chordee  sometimes  much 
modified. 

In  tiie  matter  of  injections  much  depends  ujion  Avhat  the  disease 
is  which  is  being  treated — as  to  the  value  of  early  injections  or  other- 
wise. In  very  acute  cases  the  cocaine  is  all  that  can  be  used.  In 
lesser  stages  of  inflammation  some  aid  may  be  exijected  from  the  use 
of  simple  dilute  lead- water,  or. 


Or, 


IJ   Liq.  pliimbi  subacetatis  dil.,  3  j. 

Mori)lii;r  acotatis,  gr.  j.  M. 

Zinci  sulphocarbolat.,  gr.  j-ij. 

Aqua\  3  j.  M. 


Or,  in  less  acute  forms,  aud  especially  when   the  malady  is  simple 
urethritis, 

5   Ziuci  sulph.,  gr.  j-iij. 

Aquae,  3  j.  M. 


Or, 

Or, 


Zincj  sulph.,  gr.  j-iij. 

Li(i.  plumbi  subacetatis  dil.,  3  j.  M. 

S.  Shake  before  using. 

I^   Alumiuis  exust.,  gr.  x. 

AquED,  '  §j.  M. 

Or,  if  more  astringeucy  is  required, 

5   Acid,  tannic,  gr.  v-x. 

AqucG,  §j.  M. 

The  bichloride  of  mercury  does  not  give  as  good  results  in  my 
hands  as  an  ordinary  injection  (I  do  not  now  refer  to  irrigation)  in 
the  early  as  in  the  late  stages  of  urethral  inflammation,  yet  sometimes 
very  mild  solutions  do  good  even  early  in  an  attack  ;  such  as, 

5   Hydrarg.  chlorid.  corros.,  gr.  ss. 

AqUcB,  3  xij-xxv.    M. 

A  suitable  injection  may  be  used  two  or  three  times  a  day.  It  is 
better  to  dilute  with  water  any  injection  that  it  is  proposed  to  use  the 
first  time  it  is  employed,  and  to  increase  the  strength  if  it  is  well 
borne  and  does  not  produce  the  desired  effect  upon  the  discharge. 
These  simple  means  will  cure  many  cases  of  urethritis  or  bastard  gon- 
orrhoea after  some  days.  Should  the  discharge  be  diminished  but  not 
cured,  the  strength  of  the  injections  may  be  increased  in  the  second 
week,  or  the  treatment  for  gleet  instituted  and  stricture  sought  for. 
If  on  the  other  hand  the  inflammatory  symptoms  and  discharge  in- 


URETHRAL  INFLAMMATION— TREATMENT.  fl 

crease  in  the  second  week,  then  the  malady  is  in  all  probal>ility  viru- 
lent gonorrhoea,  and  the  case  passes  on  rapidly  to  the  second  stage. 

SxATioisrARY  Stage. — In  this  stage  all  the  inflammatory  symptoms 
have  reached  a  certain  high  grade,  where  they  tend  to  remain,  for  from 
one  to  three  weeks,  with  very  little  change  from  day  to  day.  The 
treatment  of  the  first  stage,  without  any  injections,  must  be  kept  up. 
Rest,  as  nearly  absolute  as  possible,  must  be  enjoined  upon  the  patient. 

Prolonged  and  frequent  warm  baths  are  beneficial  in  this  stage. 
The  sandal-wood  oil  or  copaiba,  which  has  been  until  now  kept  up  at 
a  moderate  rate,  must  be  steadily.but  gradually  increased,  according 
to  the  tolerance  of  the  stomach,  until  the  full  dose  is  reached.  The 
approach  of  nausea,  copaibal  erythema,  or  diarrhoea,  indicates  that 
the  patient  is  saturated  with  the  remedy,  if  it  be  copaiba  ;  perhaps 
pain  in  the  back,  if  it  be  sandal-wood  oil.  Patients  can  rarely  take 
more  than  thirty  minims  at  a  dose. 

The  maximum  dose  must  be  maintained  for  a  week.  If  at  the 
end  of  that  time  a  positive  effect  is  not  produced,  the  drug  in  use 
should  be  changed,  or,  possibly,  combined  with  some  preparation  of 
cubebs.  Should  retention  come  on,  and  it  is  one  of  the  rarest  com- 
plications, a  finger  in  the  rectum  will  usually  make  out  a  swollen, 
hot,  tense  prostate,  as  large  as  an  egg,  which  throbs  against  the  end 
of  the  finger,  and  is  very  sensitive  to  pressure.  Under  these  circum- 
stances, fifteen  or  twenty  leeches  may  be  applied  to  the  perinaeum ; 
that  many,  or  none.  They  are  rarely,  if  ever,  absolutely  necessary. 
The  patient  must  be  kept  warm  in  bed,  with  hot  fomentations,  or  a 
light  poultice  or  water-bag,  over  the  hypogastrium  and  perinseum  ;  or 
he  may  take  a  hot  sitting-bath  for  a  few  minutes  at  a  time  every  half- 
hour.  The  water  must  be  above  100°  Fahr.,  and  the  bath  of  short 
duration.  The  patient  should  be  plied  with  mucilaginous  drinks 
(flaxseed-tea,  etc.),  and  get  the  equivalent  of  about  one  grain  of  ojDium 
every  hour  until  the  urine  flows,  which  it  invariably  will  do  unless 
rather  a  tight  organic  stricture  existed  before  the  gonorrhoeal  attack. 

In  any  case  of  great  urgency  a  small,  about  ISTo.  14  French  scale, 
soft  olivary  catheter,  without  a  stylet,  may  be  very  gently  introduced, 
or,  indeed,  failing  this,  the  aspirator  employed  ;  or  Cazeuave's  expe- 
dient of  ice  in  the  rectum  might  be  tried. 

The  most  difficult  part  of  the  treatment  of  the  stationary  stage  is 
to  soothe  the  painful  erections  and  keep  off  chordee.  This  can  only 
be  effected  measurably.  ISTo  anaphrodisiac  has  yet  been  discovered. 
Camphor,  belladonna,  conium,  bromide  of  potassium,  ergot — not  one 
of  these  possesses  the  virtues  attributed  to  it.  The  best  course  is  for 
the  patient  to  keep  his  urine  dilute  and  alkaline,  avoid  lascivious 
thoughts,  and  resort  to  prolonged  immersions  of  the  penis  in  very  hot 
water  before  retiring.  He  should  sleep,  lightly  covered,  on  his  side 
rather  than  on  his  back,  on  a  hard  bed,  after  a  small  evening  meal,  in 


72  DISEASES  OF  THE   URETHRA. 

a  cool  room  ;  and,  if  necessary,  use  as  medicines  large  doses  of  lupulin 
or  opium  in  pill  or  suppository,  preferably  the  former.  Lujjuliu 
rubbed  up  into  gr.  iv  pills,  or  taken  in  powder  with  sugar,  is  of  un- 
doubted service,  simply  because  it  promotes  profound  sleep.  But  the 
dose  must  be  large.  Less  than  gr.  xx  is  useless,  and  from  3  ss  to  3  j  may 
be  given  on  retiring.     No  constijiation  or  other  bad  symptom  follows. 

Bromide  of  potassium,  in  doses  of  from  tliirty  to  sixty  grains  at 
night  in  water,  repeated  once,  if  necessary,  will  control  chordce  in 
some  cases.  The  cocaine  urethral  injections  seem  also  to  have  some 
value,  but  in  some  cases  nothing  short  of  opium  or  morpliine,  pref- 
erably in  su]ipository,  can  be  trusted  to  subdue  the  symptom. 

When  a  patient  wakes  with  chordee,  the  penis  should  be  jslunged 
into  the  coldest  water  which  is  at  hand,  or,  what  is  better,  if  it  is  win- 
ter, laid  along  a  piece  of  iron  (axe-head,  railing),  or  otlier  metal, 
which  lias  been  exposed  to  the  cold.  The  bladder  should  be  emptied  as 
promptly  as  possible.  The  patient  must  be  strongly  cautioned  against 
breaking  the  chordee.  If  this  is  done,  the  immediate  effect  is  relief  of 
pain,  but  the  inevitable  ultimate  consequence  is  traumatic  stricture. 

Decreasing  Stage. — The  slightest  falling  off  in  the  amount  of 
discharge,  or  in  the  pain,  or  other  inflammatory  symptom,  ushers  in 
this  stage.  Chordee,  however,  may  persist  long  after  it  has  been 
reached.  The  time  of  its  advent  depends  considerably  upon  the  suc- 
cess of  previous  medication.  Advantage  must  be  taken  of  this  tend- 
ency of  the  discharge  to  decrease.  Hygiene  and  alkali  should  be 
kept  up,  and  the  balsam  or  oil  of  sandal-wood  pushed.  The  stomach 
has  already  become  accustomed  to  its  presence,  and  will  usually  allow 
the  dose  to  be  increased.  If  the  discharge  diminishes  rapidly,  the 
remedy  should  be  held  at  full  dose,  but  not  increased.  Earely  more 
than  three  or  four  capsules  at  a  dose  (gtt.  xxx  to  xl)  will  be  needed, 
or  indeed  tolerated.  It  is  exceedingly  desirable  not  to  disgust  the 
stomach  with  the  copaiba,  as  this  necessitates  its  discontinuance.  If 
copaiba  is  well  borne  and  properly  administered,  it  is  the  most  effi- 
cient of  the  anti-gonorrhoeal  internal  remedies. 

Each  of  the  drugs — copaiba,  sandal-wood  oil,  cubebs,  oil  of  turpen- 
tine— imparts  an  odor  to  the  urine  peculiar  to  itself.  Besides  its  dis- 
agreeable action  on  the  stomach,  large  doses  of  copaiba  (in  certain  in- 
dividuals even  small  doses)  give  rise,  in  some  cases,  to  a  peculiar  ex- 
anthema resembling  roseola. 

CoPAiBAL  Erythema. — This  eruption  consists  in  the  appearance 
upon  the  whole  body  of  small  red  blotches,  closely  aggregated,  slightly 
elevated,  causing  a  tingling,  hot,  itcliy  sensation.  The  eruption  is 
unimportant,  and  subsides  in  a  few  days  if  the  remedy  be  discontin- 
ued. It  is  sometimes  mistaken  by  young  practitioners  for  a  syphilitic 
roseola.  The  rapidity  of  its  appearance,  the  hot,  inflammatory  char- 
acter of  the  patches,  the  itching  and  tingling  of  which  the  patients 


URETHRAL  INFLAMMATIOX— TREATMENT.  73 

complain,  are  sufficient  to  make  the  diagnosis.  The  pain  and  itching 
are  soothed  by  a  warm  bath.  In  these  cases  the  urine  always  smells 
strongly  of  copaiba.  Wlien  such  a  rash  comes  on  the  urethral  dis- 
charge ceases,  but  it  will  reappear  as  the  eruption  fades.  Conse- 
quently it  is  not  wise  to  discontinue  treatment.  It  is  simply  neces- 
sary to  change  the  drug.  Urticaria,  or  "hives,"  may  also  be  excited 
by  the  ingestion  of  copaiba,  and  certain  obscure  nervous  phenomena 
have  also  been  referred  to  its  use,  such  as  headache  and  giddiness. 
Severe  pain  in  the  lumbar  regions  is  excited  in  some  individuals  by 
the  use  of  sandal-wood  oil  in  excess. 

Thus  far  nothing  has  been  said  about  cuhebs.  The  different  prep- 
arations of  this  remedy  are  more  stimulating  than  copaiba  or  sandal- 
wood, and  are  consequently  better  adapted  to  combat  the  subacute 
and  distinctly  retiring  forms  of  inflammation  than  the  advancing  or 
stationary.  They  are  very  aj)plicable  to  the  latter  jDortion  of  the 
stage  of  decline,  and  to  the  gleety  stage.  As  a  rule  they  are  well 
borne  by  the  stomach,  often  increasing  the  appetite,  and  allaying  dys- 
peptic symptoms.  Occasionally  the  stomach  rebels  even  against  cubebs. 
Of  the  powder,  the  dose  is  from  one  to  two  drachms  in  sweetened 
gum-water.  The  fluid  extract,  in  drachm-doses,  is  efficacious  and  not 
unpalatable  ;  but  the  most  efficient  preparation  is  the  oleo-resin. 
This  may  be  administered  in  capsules  containing  gtt.  x.  The  dose  is 
from  one  to  three  capsules.  By  changing  from  one  to  the  other  of 
these  three  remedies,  in  sluggish  cases,  the  effect  of  each  seems  to  be 
increased.  The  compound  prescriptions  and  pastes,  containing  both  co- 
paiba and  cubebs  and  other  substances  in  varying  quantities,  often  are 
found  clinically  to  act  better  than  any  one  of  the  substances  alone — 
but  there  is  no  one  thing  that  acts  equally  "well  in  all  cases.  The  pre- 
scription already  given  when  speaking  of  the  advancing  stage  is  some- 
times very  advantageously  modified  by  adding  to  it  a  little  fluid  ex- 
tract or  even  oil  of  cubebs. 

If  the  bursting  of  the  capsules  in  the  stomach  tends  to  nauseate, 
the  pilulge  copaibse,  TJ.  S.,  may  be  used.  These  dissolve  slowly,  and  are 
sometimes  less  offensive.  Some  oleo-resin  of  cubebs  may,  if  necessary, 
be  included  in  their  composition.  Turpentine  and  other  so-caUed 
anti-blenorrhagic  medicines  are  unreliable  in  comparison  with  the 
three  already  mentioned,  but,  like  cantharides,  are  of  some  use  toward 
the  end  of  an  attack. 

To  recapitulate,  balsam  of  copaiba  is  the  best  preparation,  and  is 
applicable  to  all  stages  of  the  disease,  but  some  individuals  can  not 
tolerate  it,  and  in  some  it  produces  derangement  of  the  stomach,  skin, 
and  nervous  system,  unless  used  with  prudence  and  skill. 

More  attention  is  necessary  for  its  successful  administration  than 
is  usually  bestowed  upon  it.  Steadily  carried  up  to  the  full  dose  in 
the  stationary  stage,  with  close  attention  to  the  gastric  capacities  of 


74  DISEASES   OF   THE   URETHRA. 

the  patient,  it  is  capable  of  being  highly  efficient.  "Within  one  week 
after  saturation  has  been  reached,  the  full  effect  of  tlie  remedy  is  at- 
tained. If  at  the  end  of  this  time  the  stomach  can  bear  no  more,  and 
the  discharge  is  unmodified,  tiie  oleo-resin  of  cubebs  should  be  com- 
bined with,  or  substituted  for,  the  copaiba.  The  above  statements 
only  apply  to  manageable  cases  where  urethral  hygiene  has  been  main- 
tained. Protracted  employment  of  full  doses  of  copaiba  is  damaging 
to  the  stomach,  and  rarely  of  service  in  curing  the  disease  if  the  first 
effect  have  failed. 

Oil  of  yelloio  sandaJ-ioood  is  a  most  excellent  remedy  ;  in  some 
cases  certainly  doing  better  than  copaiba.  It  is  not  objected  to,  as 
a  rule,  by  the  stomach,  but  may  produce  severe  pain  in  the  loins.  It 
is  applicable  to  all  stages  of  the,  disease.  The  maximum  curative  ef- 
fect is  usually  noticed  during  the  week  after  the  full  dose  of  the  rem- 
edy has  been  attained. 

Oleo-resin  of  cubehs  is  usually  well  borne  by  the  stomach.  It  may 
produce  slight  diarrhoea  (as,  indeed,  may  copaiba  or  sandal-wood).  It 
is  fitted  for  treating  subacute  and  chronic  cases,  or  for  use  in  com- 
bination with  either  of  the  other  so-called  specifics.  It  sometimes 
produces  symptoms  of  vesical  irritability,  particularly  if  used  freely. 

These  three  remedies  may  be  alternated,  commencing  with  sandal- 
wood and  ending  with  cubebs.  The  last  one  in  use  when  the  dis- 
charge has  ceased  should  be  continued  for  at  least  ten  days — one  cap- 
sule less  being  taken  daily  until  the  remedy  is  gradually  dropped. 

These  remedies  have  been  found  ineffective  when  given  by  the 
rectum.  Their  action  is  a  local  one.  They  undergo  a  change  in 
passing  through  the  kidney,  and  are  excreted  with  the  urine.  It  is 
the  contact  of  this  urine  with  the  inflamed  surface  of  the  urethra 
which  produces  the  benefit;*  consequently  they  are  useless  in  the 
female  unless  the  urethra  is  affected. 

Injections  are  of  great  service  in  the  stage  of  decline.  Any  of  the 
formulae  of  page  70  may  be  used,  commencing  with  the  milder  and 
passing  on  to  the  stronger  solutions.  The  two  injections  from  which 
I  have  derived  the  greatest  advantage  in  the  declining  stage  are  the 
following  : 


And 


5   Hydrarg.  cblorid.  corros.,  gr.  ss. 

Aqutc,  §  xij-iv.      M. 


IJ   Zinci  permanganat.,  gr.  ss-ij. 

Aquie,  gj.  M. 

Some  cases  can  not  use  bichloride  solutions  at  all  on  account  of  the 
pain  caused. 

*  As  has  been  proved  in  cases  of  large  fistula  in  the  floor  of  the  urethra  where  the 
urine  could  be  turned  off,  the  part  behind  the  opening  getting  well  first — the  anterior  part 
of  the  urethra  being  subserjuently  cured  by  being  injected  with  the  patient's  urine,  freshly 
passed  and  full  of  modified  copaiba. 


TREATMENT   OF   GLEET.  75 

Gleety  )Stage. — A  gleet  is  a  mucoid  discharge  from  tlie  uretlira. 
All  urethral  discharges  become  gleety  before  they  cease,  and  sucli  a 
gleet,  following  upon  an  uncomplicated  gonorrha-a,  tends  to  get  well 
by  the  simple  observance  of  the  hygiene  of  the  urethra.  This  rule, 
however,  has  many  exceptions.  In  undertaking  the  treatment  of  a 
gleety  discharge,  its  cause  must  be  studiously  sought  out  and  treat- 
ment applied  accordingly.  Sometimes  the  patient  requires  treatment 
more  than  the  urethra — as  in  idiopathic  gleet  from  strumous  or  gouty 
tendency.  In  such  cases  the  observance  of  hygiene,  as  affecting  the 
urethra,  with  alkali,  cod-liver  oil,  quinine,  and  iron,  constitutes  the 
outline  of  treatment.  Of  the  tonic  preparations,  the  tincture  of  the 
sesquichloride  of  iron  holds  the  first  rank,  on  account  of  its  astringent 
properties.  Excess  of  treatment  is  not  infrequently  the  cause  of  pro- 
longation of  gleet,  the  patient,  either  with  or  without  a  physician's 
advice,  trying  blindly  one  injection  after  another,  and  all  sorts  of  in- 
ternal medication,  importuning  his  friends  for  their  "  infallible  "  pre- 
scriptions, and  worrying  his  urethra  with  endless  interference,  search- 
ing for  a  specific  which  he  can  not  find,  notwithstanding  the  countless 
number  which  are  confided  to  him  by  sympathizing  companions.  In 
such  a  case  the  best  medication  is  to  reassure  the  patient  and  instruct 
him  in  everything  relative  to  urethral  hygiene,  leaving  the  canal 
entirely  alone  for  a  week,  simply  watching  to  see  what  the  discharge 
really  amounts  to. 

Everything  earthly  has  an  end,  even  a  gleet,  as  Thiry  has  sagely 
remarked,  and  no  treatment  will  sometimes  succeed  where  over-treat- 
ment has  only  served  to  keep  up  the  evil.  Such  cases  are  found 
chiefly  in  unmarried  young  men,  who  are  kept  in  a  constant  morbid 
state  of  excitement  about  their  genitals  by  ungratified  sexual  desire, 
or  its  irregular  or  excessive  indulgence.  In  these  cases  the  "dis- 
charge "  may  be  invisible  except  to  the  patient,  a  slight  gluing  of  the 
meatus  in  the  morning  being  the  only  tangible  evidence  that  some- 
thing is  wrong.  Here  the  mind  is  often  more  diseased  than  the  body, 
and  marriage  is  the  proper  remedy.  A  regular,  moderate  exercise  of 
the  sexual  organs  tends  surely  to  keep  down  congestion  and  to  allow 
that  rest  which  is  most  important  in  efi:ecting  a  cure.  Yet  care  must 
be  exercised  in  advising  marriage,  if  the  discharge  be  at  all  purulent 
and  contains  gonococci.  No  such  pus  can  be  pronounced  free  from 
contagious  properties,  although,  practically,  in  my  experience  it  has 
sometimes  turned  out  to  be  so.  In  all  cases  of  prolonged  purulent 
gleet,  a  lesion  in  the  urethra  (stricture,  granulations)  should  be  sought 
for  and  treated.  If  not  found,  and  if  no  gonococci  are  present,  mar- 
riage is  proper,  and  not  only  not  harmful  but  even  beneficial  in  its 
effect  upon  the  discharge. 

The  most  common  of  all  causes  for  continued  gleet  is  stricture 
already  present  or  forming.     Special  causes  of  gleet  require  special 


76  DISEASES   OF  THE   URETHRA. 

means  of  treatment,  ami  will  be  mentioned  under  their  respective 
heads.  They  are  :  lacunul  inllammation,  chronic  co\vi)eritis,  inlhim- 
mation  of  the  seminal  vesicles,  hYpertroi)hy  of  the  prostate,  conges- 
tion, catarrhal  inflammation,  tubercular  or  other  prostatic  disorder 
(abscess,  etc.),  fistula  with  internal  opening,  peri-urcthral  abscess, 
diathetic  idiosyncrasies,  mucous  patches  in  the  urethra,  etc.  Next  to 
stricture,  an  altered  congested  patch  of  urethral  membrane,  with  or 
without  thickening  or  granulations,  is  the  most  common  lesion  keep- 
ing up  a  gleety  discharge.  The  treatment  of  gleet  dependent  upon 
tliis  cause,  or  existing  without  urethral  or  other  appreciable  lesions, 
finds  its  proper  place  in  this  section. 

Treatment. — Where  no  lesion  is  discovered,  the  following  treat- 
ment is  advisable  :  The  urine  must  be  kejit  mildly  alkaline,  without 
oppressing  the  stomach,  hygienic  conditions  as  affecting  the  urethra 
must  be  carefully  observed,  the  provocation  of  sexual  excitement  in- 
terdicted. There  is  no  objection  to  ordinary  sexual  intercourse  if  the 
patient  be  married  and  living  with  his  wife  ;  all  extra  excitement, 
however,  during  the  act,  and  all  provocation  of  the  sexual  appetite, 
are  to  be  avoided.  The  use  of  copaiba  or  oil  of  sandal-wood,  which- 
ever may  have  been  found  serviceable  in  the  stage  of  decline  of  gonor- 
rha?a,  may  be  continued,  or  substituted  by  tiie  oleo-resin  of  cubebs  in 
moderation.  Tincture  of  iron,  quinine,  and  a  little  claret,  may  be 
ordered,  if  tlie  patient  is  anaemic  or  run  down,  and  especially  if  the 
urine  is  alkaline,  or  contains  phosiihates  in  excess.  A  stimulating  or 
astringent  injection  should  be  employed.  Any  of  the  formulae  already 
given  will  answer,  but  it  may  be  necessary  gradually  to  increase  their 
strength.  There  is  little  use  of  a  multiplicity  of  injections,  and  of 
running  from  one  to  another  in  trying  to  find  a  specific  virtue.  It 
will  be  hard  to  prevent  the  patient  from  doing  this  of  his  own  motion, 
but  his  own  dignity  should  prevent  the  surgeon  from  encouraging  the 
patient  in  his  folly.  The  fewer  the  number  of  injections  a  surgeon 
employs  the  more  good  will  he  be  able  to  cfPect  with  them.  He  will 
learn  how  to  handle  them  to  more  advantage,  and  will  understand 
their  power  for  good  or  evil.  Nearly  all  known  drugs  have  been  at 
different  times  vaunted  in  injection  for  urethral  discharge,  but  only  a 
few  hold  their  place.  Besides  the  injections  already  given,  several 
others  have  proved  serviceable  in  the  gleety  stage  :  the  chloride  of 
zinc  (gr.  j  in  the  3  j),  sulphate  of  copper  (gr.  j  in  the  3  j),  and  vary- 
ing strengths  of  alum,  tannin,  and  sulphate  of  zinc  in  combination, 
either  strong  solutions  used  occasionally,  or  weak  ones  often. 

Bumstead  praises  the  persulphate  of  iron,  3  ss  to  3  vj.  Finally, 
alcohol  is  often  efficient.  Perhaps  the  best  way  of  using  this  stimu- 
lant, which,  like  tannin,  is  indicated  where  discharge  seems  to  be  kept 
up  by  an  atonic  state  of  the  urethral  membrane,  is  according  to 
Ricord's  formula,  namely — to  commence  with  two  parts  of  rose-water 


TREATMENT   OF   GLEET.  77 

to  one  of  red  wine,  and  to  continue  increasing  the  latter  until  pure 
wine  can  be  used,  unless  the  discharge  cease  meanwhile.  Glycerin 
may  be  combined  with  any  of  the  above  formulai,  as  may  also  mor- 
phine, although  the  latter  is  rarely  of  much  service. 

The  substances  just  mentioned  h.ave  been  proved  by  long  and  gen- 
eral experience  to  be  best  adapted  to  the  treatment  of  urethral  inflam- 
mation.    Three  points  must  be  remembered  m  regard  to  injections  : 

1.  That  the  old  false  idea  about  burning  out  the  disease  is  absurd, 
and  that  the  aim  must  not  be  to  use  an  injection  as  strong  as  can  be 
borne,*  but,  on  the  contrary,  to  use  as  weak  a  one  as  will  do  any 
good. 

2.  That,  when  a  gleety  discharge  ceases  under  the  employment  of 
a  given  injection,  the  latter  should  be  continued  for  at  least  ten  days 
longer,  and  given  up  gradually. 

3.  That  in  certain  cases  the  discharge  becomes  reduced  to  a  mini- 
mum, but  will  not  wholly  cease.  In  these  cases  the  injections  are 
probably  maintaining  a  condition  of  hypersecretion  of  urethral  mucus, 
and  their  discontinuance  will  cause  the  discharge  to  cease. 

In  a  general  way,  it  may  be  said  of  injections  that  they  are  among 
our  best  weapons  for  fighting  gleety  discharges,  if  used  correctly,  of  a 
proper  strength,  and  at  the  right  time. 

Like  all  good  things,  they  may  be  abused.  Any  injection  strong 
enough  to  bring  blood  may  be  the  starting-point  of  stricture.  Any 
injection,  thrown  too  deeply  into  the  canal,  may  light  up  epididymitis 
or  cystitis  of  the  vesical  neck.  No  injection  should  cause  actual  jDain. 
A  sense  of  smarting  and  warmth,  lasting  a  few  minutes,  is  not  objec- 
tionable. 

Carefully  performed  deep  urethral  injections  may  be  used  with 
advantage  when  the  surface  from  which  the  discharge  comes  is  situated 
in  the  membranous  urethra  or  thereabouts.  To  inject  projoerlv, 
I  believe  that  a  very  small  amount  of  fluid  should  be  used,  not  more 
than  three  minims,  and  that  it  should  be  deposited  accurately  upon  the 
inflamed  area.  After  long  using  with  little  success  various  sjringes 
furnished  with  lateral  minute  perforations,  I  have  come  to  depend 
exclusively  upon  a  syringe  with  one  small  perforation  at  its  terminal 
end  (Fig.  24).  Having  located  the  granulating  area  with  a  bulb  or 
otherwise,  the  tip  of  this  syringe  is  to  be  carried  down  to  the  proper 
depth,  and  there  a  deposit  of  three  minims  to  be  placed.  I  rely  for 
deep  urethral  injection  almost  entirely  upon  solutions  of  nitrate  of 
silver  of  a  strength  of  gr.  j  to  grs.  xx — occasionally  even  grs.  xlviij 
to  the  ounce — according  to  effect,  repeating  the  application  not  oftener 

*  William  M.  Mastin  reports  a  case  of  tubular  sloughing  of  the  entire  length  of  the  ure- 
thra "  involving  the  mucous  and  sub-mucous  tissues,"  caused,  he  believes,  by  using  a  sat- 
urated solution,  in  water,  of  the  sulphate  of  zinc  and  acetate  of  lead  four  times  a  day  for 
urethritis. — "Ann.  of  Anatomy  and  Surgery,"  ISSl,  p.  274. 


78  DISEASES  OF  THE  URETHRA. 

than  three  times  a  week,  and  at  lengthening  intervals  as  the  strength 
of  the  solntion  is  increased.  If  this  method  is  snitable,  each  injec- 
tion produces  a  more  or  less  ]ironounccd  el?ect  n])on  tlio  discharge  ;  if 
improvement  is  not  manifest  after  two  or  three  injections,  it  is  useless 


^ 


^■\aViU*t>.H*,«  M»t&CO. 


Fig.  -Zi. 


to  continue  the  course.  Occasionally  a  fifty-per-ccnt  solution  in  water 
of  the  glycerole  of  tannin  will  arrest  a  deep  urethral  discharge  after 
the  nitrate  of  silver  fails.  1  have  experimented  with  many  other  sub- 
stances only  to  discard  them.  The  deep  urethral  syringe  has  almost 
entirely  disphiced  in  my  practice  the  use  of  the  various  medicated 
soluble  bougies  and  the  cupped  sound  with  tan  no-glycerin  paste. 

Another  kind  of  injection,  called  isolating,  higlily  praised  by 
Caby,*  is  still  occasionally  resorted  to.  It  consists  in  throwing  in 
bismuth,  or  calamine,  or  chalk,  suspended  in  a  sticky  fluid,  or  as 
soluble  suppositories — the  object  being  to  coat  over  the  walls  of  the 
urethra  with  one  of  these  insoluble  powders.  They  sometimes  act 
efEcctivcly,  bat  often  cause  a  good  deal  of  discomfort  from  the  collec- 
tion of  little  hard  lumps  of  bismuth  and  mucus  along  the  canal.  The 
following  is  a  good  type  of  this  style  of  injection,  combined  with  a 
mild  stimulant : 

R    Zinci  sulph.,  gr.  j-ij. 

Bismuth  subnitratis, 

Pulv.  acacite,  iia  3  j- 

Aqua?,  3  iv.         M. 

Shake  thoroughly  before  using. 

Milton  is  loud  in  praise  of  blistering  the  penis  externally,  com- 
bined with  mild  astringent  injection  ;  but  this  treatment  is  altogether 
too  severe  for  general  adoption.  Electricit}",  both  the  continued  and 
the  induced  currents,  internally  and  externally  applied,  has  been 
vaunted  for  the  cure  of  gleet.     In  my  hands  it  has  proved  of  no  value. 

Gleet,  unconnected  with  serious  urethral  lesions,  gets  well  under 
treatment  by  injection.  If  the  discharge  remains  gleety  a  fortnight  or 
more,  even  if  there  be  no  urethral  lesion  of  importance,  a  well-oiled, 
conical,  smoothly-polished  sound,  as  large  as  the  meatus  will  com- 
fortably admit,  should  be  passed  into  the  bladder,  with  the  utmost 
gentleness  and  slowness,  and  withdrawn  at  once  with  the  same  delib- 
eration and  care.      This  simple  operation,  repeated  every  third  or 

*  "Nouveau  Mode  de  Traitcmcnt  de  divers  Affections  g^nitaux  chez  I'llomme  ct  chez 
la  Femme  par  rEmploie  de  Sous-nitrate  de  Bismuth."     Thtse,  Paris,  1858. 


TREATMENT   OF   GLEET.  Y9 

fourth  day,  will  rarely  fail  to  cure  the  discharge.  The  sensibility  of 
the  canal  becomes  blunted  by  contact  with  the  instrument,  its  irrita- 
bility overcome  by  tlie  slight  distention  to  which  it  is  subjected,  while 
the  tonic  effect  of  the  cold  metal  is  also  probably  a  factor  in  produc- 
ing the  good  effect.  A  steel  instrument  is  much  better  than  a  soft 
bougie.  There  is  no  object  in  leaving  the  instrument  longer  in  the 
canal  than  it  takes  to  pass  it  slowly  into  the  bladder  and  as  slowly 
withdraw  it.  The  instrument  must  fill  without  stretching  the  meatus. 
The  meatus  may  be  congenitally  small,  and  this  alone  may  keep  up 
a  discharge.  In  such  a  case  a  little  poach  can  be  felt  with  a  bent 
probe,  formed  behind  the  lower  commissure  of  the  meatus.'  Such  a 
condition  may  be  promptly  relieved  by  incising  the  meatus.  This  sim- 
ple oj)eration  occasionally  cures  a  gleet  of  long  standing. 

Finally,  in  regard  to  instruments,  the  greatest  care  and  gentleness 
should  be  employed.  Used  too  often  or  clumsily,  they  do  harm  by  in- 
creasing the  grade  of  inflammation,  or  joossibly  bringing  on  an  attack  of 
epididymitis.  In  the  cases  under  consideration,  no  instrument  should 
be  reintroduced  until  all  irritation  and  teirfporary  increase  of  discharge, 
produced  by  its  previous  use,  have  subsided  for  twenty-four  hours. 

Where  patches  of  urethral  congestion  keep  up  a  discharge,  they  may 
be  detected  by  passing  a  full-sized  bulbous  bougie  into  the  bladder. 
When  the  head  of  the  instrument  reaches  the  altered  spot,  the  patient 
will  complain  of  slight  pain,  which  will  disappear  as  the  bulbous  head 
of  the  instrument  passes  on  to  the  healthy  urethra  beyond.  Any  little 
thickening  in  the  walls  of  the  canal  is  recognized  at  the  same  time. 
Furthermore,  if  a  patient  with  one  of  these  patches  makes  water  into  a 
glass  vessel,  and  the  fluid  be  held  up  to  the  light,  one  or  more  thready 
filaments  may  be  seen  gradually  sinking  through  the  urine.  If  one  of 
these  be  caught  and  placed  under  the  microscope,  it  will  be  found  to 
consist  of  pus-corpuscles  adhering  together  ;  in  other  words,  it  is  a 
soft  scab,  and  indicates  that  a  portion  of  urethra  is  not  covered  by 
healthy  epithelium,  but  is  abraded  (not  ulcerated),  and  covered  by 
soft,  round  leucocytes.  These  shreds  are  always  found  in  cases  of 
forming  stricture,  in  every  stage  of  the  complaint. 

When  these  signs  of  urethral  lesion  exist,  the  gentle  use  of  the  steel 
sound  becomes  the  first  requisite  of  treatment.  The  balsams  may  be 
discontinued,  and  injections  become  of  secondary  importance.  Ure- 
thral hygiene  (p.  43),  and  the  gentle,  persevering  use  of  a  full-sized 
conical  steel  sound,  will  often  effect  a  cure.  In  some  cases  the  '^cold- 
sound"  (Winternitz  *),  a  closed  silver  tube  like  a  catheter,  with  a  par- 
tition running  down  centrally  within,  nearly  up  to  the  tip,  so  that 
water  injected  into  one  of  the  compartments,  after  circulating  through 
the  instrument,  runs  out  from  the  other  compartment,  is  worth  a  trial. 
I  use  iced  water  for  about  five  minutes,  and  reajsply  about  every  second 

*  "  Berl.  klin.  Wochenschrift,"  July  9th,  IS?*?. 


80  DISEASES  OF  THE  URETHRA. 

day.  In  some  cases  of  urethral  neuralgia  and  of  pollution  also,  this 
instrument  yields  good  results. 

The  endoscope  is  of  some  service  in  treating  obstinate  cases,  but  its 
aid  is  very  rarely  required.  Thompson's  remark  about  its  usefulness  is 
a  fair  criticism  :  **  If  a  man  has  a  good  and  tolerably  practiced  hand, 
with  a  fair  share  of  intelligence,  I  do  not  think  he  will  gain  a  great 
deal  by  the  endoscope  ;  and,  if  he  has  not,  I  think  it  Avill  be  of  no  use 
at  all."  Yet  the  altered  spots  of  urethral  membrane  can  be  very  clearly 
seen  through  the  endoscope,  granulations  can  be  detected  where  they 
exist,  and  local  applications  of  considerable  strength  made,  which 
could  not  be  applied  with  safety  by  any  other  means.  The  expensive 
and  complicated  instruments  of  Desormcaux,  Cruise,  and  modifica- 
tions of  the  same,  are  but  little  if  at  all  better  than  a  simple  straight 
urethral  tube  of  black,  hard  rubber  furnished  with  an  obturator.  The 
silver  tube  known  as  Klotz's  endoscope  answers  well.  All  the  illumi- 
nation required  for  these  tubes  may  be  obtained  by  reflection  from  a 
concave  mirror  strapped  to  the  forehead.  For  examining  the  deep 
urethra,  however,  direct  sunlight  or  a  strong  artificial  light  is  neces- 
sary for  illumination. 

To  make  a  thorough  inspection,  the  tube  should  be  introduced  well 
into  the  membranous  urethra,  the  obturator  withdrawn,  the  oil  and 
mucus  wiped  away  from  the  membrane  presenting  at  the  bottom  of  the 
tube,  and  then,  tlic  illumination  being  brought  to  bear,  each  successive 
portion  of  membrane  may  be  inspected  as  the  tube  is  withdrawn.  The 
healthy  mucous  membrane  has  a  pale-pink  color,  and  contrasts  strongly 
with  congested  spots,  which  are  of  a  vinous  red  without  polish.  Such 
spots  can  be  plainly  seen  as  they  come  across  the  end  of  the  tube,  and 
any  granulations  upon  them  are  readily  recognized  by  the  practiced 
eye.  The  topical  remedy  for  granulations  suggested  by  Desormeaux, 
and  which  can  be  very  accurately  ai^plied  through  the  tube  by  means  of 
a  little  cotton  twisted  upon  a  long  probe,  is  a  solution  of  nitrate  of  sil- 
ver of  from  3  ij  to  the  3  j  up  to  the  saturated  solution.  The  latter 
should  be  only  used  in  the  case  of  large  granulations,  and  then  is  to 
be  very  sparingly  applied.  Iodine,  sulphate  of  copper,  tannin,  car- 
bolic acid,  etc.,  used  as  local  applications,  give  fair  results.  The  ad- 
vantages of  treating  by  the  endoscope  are,  that  the  spot  to  which  an 
application  has  been  made  may  be  inspected  from  week  to  week,  and 
the  effect  of  treatment  critically  observed.  This  topical  treatment  is 
to  be  repeated  at  first  twice  a  week,  then  weekly  for  several  months. 

W.  T.  Belfield,*  of  Chicago,  has  an  excellent  chapter  on  endoscopy. 
He  is  the  exponent  in  this  country  of  the  views  of  Josef  Griinfeld, 
of  Vienna,  whose  work  f  and  instrument  he  extols.     The  electric  cys- 

*  "Diseases  of  the  Urinary  and  Male  Sexual  Organs,"  New  York,  18S4,  p.  69. 
t  "Die  Endoskopie  dcr  Harnrolire  und  Blase,"  one  of  the  volumes  of  Billroth  and 
Liickc's  "  Deutsche  Chirurgic." 


SEQUELS   OF   GONORRUffiA.  gl 

toscope  of  JSTitzc,  made  by  Ilartwig,  of  Berlin,  is  an  analogous  in.stru- 
mcnt  for  inspecting  the  bladder.  It  has  a  visual  field,  it  is  claimed,  of 
considerable  size.  Leiter,  of  Vienna,  makes  also  an  admirable  endo- 
scoi)e  and  cystoscope  illuminated  by  an  electrical  lamp. 

SEQUELS   OF   GONOERHCEA. 

Certain  unusual  sequelae  of  gonorrhoea  may  be  mentioned  here  be- 
fore entering  into  a  detail  of  its  complications.  After  discharge  has 
absolutely  ceased,  the  patient  is  usually  as  well  as  he  was  before  ;  but 
there  are  exceptions.  Among  the  most  frequent  of  these  is  pain  on 
passing  water,  ranging  from  an  itching  up  to  an  absolute  burning ; 
and  this  neurosis  may  last  from  a  few  months  up  to  many  years. 

The  pain  may  be  confined  to  erections  and  ejaculations,  the  latter 
depending  upon  some  disturbance  at  the  prostatic  sinus.  There  may 
be  urethral  j^ains  independent  of  erection  or  urination,  sometimes  se- 
vere in  character — perhaps  paroxysmal — and  known  as  urethral  neu- 
ralgia.* These  different  kinds  of  pains  disappear,  as  a  rule,  in  a  few 
weeks  or  months.  No  treatment,  except  the  observance  of  urethral  hy- 
giene, seems  to  be  of  much  service.  If  they  persist,  t.here  is  probably 
some  lesion  of  the  canal,  even  although  there  be  no  discharge.  Where 
there  is  no  lesion,  a  resumption  of  the  physiological  exercise  of  the 
organ  tends  greatly  to  reduce  the  abnormal  sensibility  of  the  urethra. 
The  judicious  use  of  steel  sounds  at  intervals,  and  the  local  employ- 
ment of  electricity,  seem  to  hasten  a  cure.  Where  the  trouble  per- 
sists, a  careful  search  should  be  made  for  stricture  or  deep  urethral 
congestion. 

A  condition  of  irritability  of  the  neck  of  the  bladder  is  sometimes 
left  behind  by  gonorrhoea,  attended  by  frequent  desire  to  urinate,  and 
sometimes  a  spasmodic  action  of  the  detrusor  during  micturition  (neu- 
ralgia of  the  vesical  neck).  The  urethra  sometimes  remains  inelastic, 
causing  a  little  dribbling.  Both  of  the  above  sequelas  are  overcome  by 
hygiene  and  the  steel  sound. 

Castelnan  f  mentions  a  singular  condition  of  prostatic  and  urethral 
anaesthesia — the  patient  having  no  orgasm,  and  being  unconscious  of 
the  passage  of  semen — left  behind  by  gonorrhoea,  and  coinciding  with 
an  inflammatory  engorgement  of  the  urethra.  The  normal  sensation 
returned  after  several  months. 

Various  other  unimportant  functional  troubles  have  been  men- 
tioned as  sequels  of  gonorrhoea. 

*  The  disease  formerly  known  as  "  dry  gonorrhcea  "  is  simply  urethral  neuralgia,  com- 
ing on  alone  without  any  antecedent  gonorrhcsa — the  canal  not  being  inflamed,  nor  the 
malady,  in  any  sense,  a  gonorrhoea. 

f  "  Observation  de  Blennorrhagie  suivie  de  Douleurs  et  d' Abolition  de  la  Sensation 
agreable  pendant  le  Coit,"  "  Ann.  des  Mai.  de  la  Peau  et  de  la  Syph.,"  lS43-'44,  tome  i, 
pp.  148-151. 

6 


82  COMPLICATIONS  OF  GOXORRUlEA, 


CHAPTEE  IV. 
COMPLICATIONS  OF  QONOEKHCEA. 

Folliculitis.— Inflammation  of  Lncnna  Magna.— Cowperitis. — Peri-uretliiit is.— Adenitis.— Lymphnn- 
gitis.— Cionorrhaal  Uheumatism  ;  Hydrarthrosis,  Inflammatory,  aflVcting  Sheaths  of  Tendons  ; 
Bursic- Diagnostic  Table  of  Simple  and  Gonorrhoea!  Uheumatism.— Cionorrluval  Ophtliaimia. — 
Gonorrhieal  Conjunctivitis. —Diagnostic  Tabic  of  Gouorrha-al  Conjunctivitis  and  Gonorrha-al 
Ophthalmia. 

FoLLiccLiTis. — During  the  acute  stage  of  gonorrhoea,  sometimes 
there  ajipear  along  tlie  urethra,  especially  in  the  region  of  the  fossa 
navicularis,  one  or  more  small,  round  tumors,  slightly  sensitive  to 
pressure,  varying  from  the  size  of  the  head  of  a  large  pin  to  that  of  a 
pea.  These  tumors  are  cysts  by  occlusion  of  the  mouths  of  the  lacuna? 
of  Morgagni.  Inflammation  seals  the  orifice  of  the  follicle,  and  the 
lacuna  is  converted  into  a  cyst  containing  pus.  As  the  latter  contin- 
ues to  be  produced,  the  cyst  enlarges.  The  pain  accompanying  it  is 
insignificant,  and  the  little  lump  is  detected  by  accident.  It  feels  like 
a  hard  ball  movilig  under  tlie  skin  and  attached  by  a  pedicle.  This 
pedicle  is  the  obliterated  neck  and  orifice  of  the  follicle.  The  little 
tumor  tends  to  remain  stationary  for  some  time,  and  then  suddenly  to 
enlarge,  soften,  involve  the  integument,  open  externally  (very  rarely 
into  the  urethra),  and,  after  discharging,  remain  fistulous  for  a  long 
time  ;  not,  however,  communicating  with  the  urethra.  These  tumors 
have  been  compared  by  Ch.  Hardy,*  who  has  described  them  very  ac- 
curately, to  wens  of  the  scalp.  The  best  treatment  consists  in  incising 
the  skin  and  enucleating  the  cyst  entirely,  or  excising  a  considerable 
portion  of  its  wall,  allowing  the  wound  to  heal  by  granulation. 

Another  form  of  lacunal  inflammation  is  where  the  lacuna  magna 
in  the  roof  of  the  urethra  continues  inflamed,  pcrha])s  after  all  tlie 
lining  membrane  of  the  urethra  has  returned  to  its  normal  condition. 
The  mouth  of  this  lacuna  is  too  large  to  become  obliterated,  and  the 
result  is  a  gleety  discharge,  which  tends  to  run  on  indefinitely.  This 
condition  maybe  relieved  by  introducing  a  fine  director  along  the  roof 
of  the  urethra  until  it  is  caught  in  the  lacuna,  and  slitting  open  the 
pouch  as  recommended  by  Phillips,  f 

CowPERiTis. — Inflammation  in  and  around  Cowper's  glands  is 
rare.  It  seems  to  occur  only  in  connection  with  urethral  inflamma- 
tion.    GublerJ  has  written  exhaustively  on  the  subject.     Cowperitis 

*  "Mumoirc  sur  les  Abces  blennorrlia.':^iqucs,"  Paris,  1864. 
f  "Maladies  dcs  Voies  urinaircs,"  Pari.-^,  1860. 

X  "Des  Glandcs  de  Mory  (Tulf:;airement  Glandes  de  Cowper),  et  de  leurs  Maladies 
chez  I'Uomme."     Th5se,  Paris,  1749. 


COWrERITIS— PERI-URETIIRITLS.  83 

rarely  comes  on  before  the  tliird  or  fourth  week  of  gonorrho3a.  Sex- 
ual intercourse,  catheterism,  and  other  irritations,  have  seemed  to 
provoke  it,  but  it  may  arise  simply  from  extension  of  inflammation 
without  appreciable  immediate  exciting  cause.  Only  one  gland  is 
usually  alTcctcd — by  preference  the  left.  Both  may  be  (rarely)  in- 
volved. The  connective  tissue  around  the  gland  is  always  largely  im- 
plicated in  the  inflammation,  making  the  disease  mainly  a  peri-cow- 
peritis. 

The  symptoms  are,  painful  tension  of  the  perinreum  in  the  region 
of  the  bulb,  increased  by  sitting,  by  pressure,  by  the  friction  of  the 
pantaloons,  slight  swelling,  with  no  change  in  color  of  the  skin.  On 
palpation,  a  small,  deep,  ovoid  or  pyriform  tumor  is  felt,  the  larger 
end  toward  the  anus,  the  small  end  confounded  with  the  bulb.  It  is 
about  the  size  of  a  bean,  on  one  side  of  the  raphe,  between  the  trans- 
verse muscle  and  the  bulb.  Soon  the  surrounding  tissue  becomes  in- 
volved, and  the  tumor  is  completely  masked.  After  this  the  phenom- 
ena are  identical  with  those  of  perineal  abscess.  The  inflammation 
often  includes  the  scrotum.  It  is  limited  posteriorly  by  the  transverse 
muscle  of  the  perinaeum,  and  usually  crosses  the  raphe,  but  remains 
always  more  prominent  upon  the  side  where  the  inflammation  began. 

Constitutional  sympathy  depends  upon  the  height  of  the  inflam- 
mation. The  abscess  usually  breaks  externally.  Its  cavity  is  found 
to  be  partitioned,  the  compartments  seeming  to  represent  the  lobules 
of  the  gland  primarily  affected.  If  the  abscess  open  internally,  uri- 
nary infiltration  and  fistula  are  to  be  feared.  Hence  the  value  of  an 
early  incision. 

Simple  cowperitis  may  undergo  resolution.  It  is  supposed  that 
these  glands  are  more  or  less  inflamed  in  those  cases  of  gleet  accompa- 
nied by  painful  tension  at  the  bulbous  region.  When  peri-glandular 
inflammation  ensues,  suppuration  seems  inevitable.  Gubler  cites  a 
syphilitic  gummy  tumor  of  the  perineum,  which  occupied  the  exact 
position  of  Cowper's  gland. 

Treatment. — Early  in  the  disease,  absolute  rest,  fifteen  or  twenty 
leeches  over  and  around  the  painful  spot,  warm  baths,  a  laxative,  and 
an  alkaline  diuretic,  constitute  the  treatment.  If,  m  spite  of  these 
measui'es,  suppuration  comes  on,  it  should  be  aided  by  poultices,  and 
an  early  incision  resorted  to.  The  rule  is,  not  to  wait  for  positive 
fluctuation,  which  is  difficult  to  detect  through  the  hardened,  inflamed 
peringeum.  Pus  has  usually  formed  m  one  week.  If  it  be  not  reached 
by  the  incision,  no  harm  is  done.  The  tissues  will  become  disgorged, 
and  whatever  matter  may  subsequently  form  will  find  its  way  out 
through  the  incisions  already  made,  which  should  be  deep  and  thor- 
ough. If  retention  comes  on,  or  is  threatened,  immediate  external 
incision  is  imperative. 

Peri-Ukethritis  terminating  in  abscess.     Chordee  is  a  peri-ure- 


84  COMPLICATIONS   OF   GONORRHOEA. 

thritis,  but  lias  little  or  no  toiulcney  to  sujipnrnto,  and  jiassos  otT 
during  subsidence  of  tbe  general  inlhunnuilion.  Suppurative  ])cri- 
urethritis  is  rarely  idiopatbic.  Its  classical  causes  are  gonorrba}a,  or 
iufiltratiou- in  connection  with  stricture.  During  gonorrbooa,  suppu- 
rative inflammation  may  attack  any  portion  of  tbe  sjiongy  tissue 
around  tbe  uretbra,  but  tbere  are  two  jioints  of  election,  tbe  fossa  na- 
vicularis  and  tbe  bulb.  Anteriorly,  peri-urctbral  abscess  usually  de- 
velops on  one  side  of  tbe  fra?num.  It  may  commence  centrally,  bulge 
on  botli  sides,  and  in  tins  way  be  bi-lobed.  At  tbe  bulb,  tbe  abscess 
begins  centrally  as  a  rule.  Here  tbe  affection  is  far  more  serious. 
The  whole  perina^um  becomes  involved,  the  inflammation  perhaps  ex- 
tending back  to  and  around  tbe  anus.  The  root  of  tbe  penis  and  the 
scrotum  may  also  be  included.  Constitutional  symptoms,  usually  ab- 
sent with  abscess  at  the  fossa  navicularis,  are  invariably  present  with 
abscess  of  tbe  bulb,  their  intensity  being  proportionate  to  the  grade 
of  tbe  inflammation.  When  a  large  extent  of  spongy  tissue,  anywhere 
along  tbe  urethra,  fulls  into  suppuration,  constitutional  sympathy  is 
marked.  These  abscesses  are  only  slightly  jiainful  at  lirst,  but  they 
soon  enlarge  and  become  tender,  being  surrounded  by  a  boggy  asdema. 
Tiiey  do  not  furnish  the  shot-like  feel  of  the  little  cystic  tumors  of 
folliculitis. 

Treatment. — An  early  deep  incision  is  imperative,  long  before  pus 
can  be  made  out.  If  this  is  neglected  anteriorly,  traumatic  hypospa- 
dias may  result,  while  in  abscess  of  the  bulb  tbe  most  serious  conse- 
quences may  ensue.  The  remarks  made  in  relation  to  abscess  attend- 
ing peri-cowperitis  apjily  with  still  more  force  bere  ;  ulceration  into 
the  uretbra,  retention,  inflltration,  burrowing  of  matter,  with  all  their 
disastrous  consequences,  are  to  be  feared  if  abscess  of  the  perinjeum 
breaks  internally.  None  of  these  serious  results  are,  however,  inevi- 
table. Should  tbe  abscess  open  into  the  urethra,  the  surgeon's  duty 
is  to  watch,  and  only  to  interfere  externally  with  the  knife  when  ure- 
thral fever,  pain,  renewed  swelling,  and  local  tenderness,  with  ten- 
dency to  the  formation  of  other  purulent  collections  near  by,  warn 
him  that  urine  escapes  from  the  canal,  is  burrowing,  and  requires  an 
external  outlet  at  once.  In  such  a  case,  if  tbere  be  no  prominent 
point  to  incise  (and  any  opening  must  be  deep),  it  is  better  to  perform 
external  perineal  urethrotomy,  including,  if  possible,  all  fistulous 
tracts  in  the  incision.  The  fistula  may  require  subsequent  attention. 
Abscesses  (probably  peri-prostatic),  complicating  gonorrhoea,  occasion- 
ally occur  behind  the  triangular  ligament.  These  are  liable  to  cause 
retention,  may  discbarge  into  the  urethra,  or  may  be  opened  from  the 
rectum  after  careful  ex2:)loration. 

Among  the  rarer  complications  of  gonorrhoea  resulting  fatally, 
maybe  mentioned  pyelitis,  of  which  Murchison*  I'cports  two  cases, 

*  "Trans.  Clin.  Soc,"  London,  1876,  p.  25. 


ADENITIS— LYMPHANGITIS.  S5 

and  peritonitis  starting  from  abscess  of  the  seminal  vesicles  or  their 
ducts,  or  from  peri-prostatic  inflammation  and  sub-peritoneal  abscess 
in  the  iliac  fossa,  the  abdominal  wall,  or  lumbar  region.  Hunter  first 
alluded  to  ]3eritonitis  as  being  due  to  gonorrhoja,  and  a  number  of 
cases — some  of  them  terminating  fatally — have  been  recorded.  Fau- 
con  *  has  an  excellent  article  on  the  subject.  Hill  and  Cooper  f  quote 
some  of  these  fatal  complications.     Agncw  I  relates  a  personal  case. 

Adenitis. — Inguinal  adenitis  of  very  mild  type  may  complicate 
gonorrhoea.  Suppuration  is  very  exceptional.  In  the  strumous,  indo- 
lent adenopathy  may  persist  after  the  urethral  discharge  has  ceased. 
Should  pus  form,  it  is  not  auto-inoculable.  Treatment — if  any  is 
called  for — is  rest  and  tincture  of  aconite  and  belladonna  locally. 

Gonorrhoeal  epididymitis  and  cystitis  will  be  considered  later. 

Lymphangitis. — More  or  less  lymphangitis  is  a  common  compli- 
cation where  urethral  inflammation  runs  high.  Several  different 
forms  are  found.  They  have  been  well  described  by  Fournier.* 
Where  the  lymphatic  vessel  alone  is  involved,  no  pain  is  felt,  nor  does 
any  external  appearance  attract  the  patient's  attention.  The  finger, 
however,  detects  indurated  cords  under  the  skin,  a  dorsal  trunk  being 
usually  the  most  prominent.  The  feel  of  these  cords  is  exactly  simi- 
lar to  that  of  the  same  vessels  in  the  lymphangitis  of  infecting  chancre 
(Fournier).  If  there  be  peri-lymphangitis,  reddened  streaks  are  seen 
upon  the  sides  or  back  of  the  penis,  and  the  corded  lymphatics  are 
felt  hard,  knotty,  painful  on  pressure,  often  several  of  them  matted 
together.  They  may  be  isolated  by  the  fingers  from  the  subjacent 
parts.  There  are  painful  tension  of  the  inguinal  glands  and  oedema 
of  the  prepuce. 

The  treatment  is  rest,  emollient  dressings  (warm  lead-water  cov- 
ered with  oil-silk,  poultice),  warm  baths,  perhaps  a  few  leeches  in  the 
groin.  Occasionally  abscesses  form  along  the  course  of  the  hard  cords. 
These  should  be  opened  early,  as  the  pus  is  liable  to  burrow,  and  may 
denude  a  considerable  extent  of  the  penis. 

Another  form  of  lijmphangitis  is  that  where  the  superficial  lym- 
phatics (not  the  trunks,  although  both  may  suffer  together)  become 
inflamed  (erysipelatous  lymphangitis).  Here  a  superficial  redness, 
evenly  spread  out,  involves  the  skin,  which  is  swollen  and  very  sensi- 
tive to  the  touch.  This  affection  is  often  limited  to  the  prepuce, 
Avhich  becomes  cedematous  and  liable  to  phimosis.  If  the  whole  penis 
is  attacked,  fever  runs  high  and  the  local  distress  is  intense. 

Treatment  is  the  same  as  for  lymphangitis  of  the  trunks.  Eesolu- 
tion  is  the  rule.     Matter  may  form,  however,  and  denude  the  penis. 

*  "De  la  peritonite  et  du  phlegmon  sous  peritoneal  d'origine  blennorrhagique,"  "Ar- 
chiv.  Gen.,"  ISVY,  October,  p.  385,  and  November,  p.  549. 

f  Second  edition,  p.  542.  %  "Surgery,"  vol.  ii,  p.  468. 

*  "Nouv.  Diet,  de  Med.  et  de  Chir.  prat.,"  p.  185. 


86  COMPLICATIONS  OF  GONORRU(EA. 

This  may  be  preveuted  by  early  incisions.  Tlie  indication  for  the 
knife  is  a  porky,  doughy,  brawny  condition  of  the  iutogumcnt,  like 
that  felt  in  phlegmonous  erysipelas. 

A  hard  ceihma  of  the  preimce  may  be  left  behind  by  these  different 
forms  of  lymphangitis,  especially  in  the  neighborhood  of  the  frrenum, 
sometimes  causing  phimosis.  Lymphangitis  may  leave  the  lymphatic 
trunks  in  a  varicose  condition  (Ricord),  or  lymphatic  listula  may  re- 
sult, usually  requiring  excision  for  its  removal. 


GONORRHCEAIi    RHEUMATISM. 

At  about  the  same  time  iu  the  year  1781,  Selle  and  Swediaur  de- 
scribed an  inflammatory  articular  affection  as  dependent  upon  gonor- 
rhoea. Since  then  the  writings  of  Hunter,  Cooper,  B.  Brodie,  Bran- 
des,  Bonnet,  Diday,  Rollet,  Fournier,  and  others,*  have  established 
the  fact  that  the  connection  between  the  two  diseases  is  not  a  coinci- 
dence, but  that  a  relation  of  cause  and  effect  exists.  The  strongest 
proof  of  this  relation  lies  in  the  fact  that  certain  individuals,  not  ordi- 
narily subject  to  rheumatic  attacks,  get  a  peculiar  form  of  rheuma- 
tism when  they  get  gonorrhoea.  They  remain  well  between  tiie  gon- 
orrhoea! attacks,  but  have  a  relapse  of  rheumatism  whenever  a  new 
urethral  inflammation  is  acquired.  Brandes  gives  the  history  of  such 
a  case,  where  a  fresh  attack  of  rheumatism  attended  six  successive 
gonorrhoeas,  and  Fournier  mentions  a  case  of  quadruj^le  relapse.  I 
have  often  seen  double,  once  quadruple  relapse.  Koniger  f  chronicles 
a  patient  never  rheumatic  except  during  three  successive  gonorrhoeas 
at  two  and  a  half  years'  interval,  once  complicated  with  iritis,  once 
with  irido-choroiditis.  None  of  the  ordinary  causes  of  articular  rheu- 
matism seem  to  have  any  power  in  producing  the  gonorrhoeal  variety. 
It  is  not  the  effect  of  cold,  or  moisture,  or  fatigue  ;  nor,  indeed,  does 
its  immediate  cause  seem  to  be  any  modification  in  the  discharge,  or 
any  medicine  taken,  or  any  injection  used.  Tlie  only  known  exciting 
cause  is  an  inflammation  of  the  urethra,  secreting  pus,  and  there  is  a 
vague  suspicion  in  the  profession  that  it  is  something  analogous  to 
mild  pyjemia.     Morris  thinks  it  due  to  reflex  nervous  causes. 

When  tliis  complaint  has  once  complicated  a  gonorrhoea,  the 
chances  are  that  every  succeeding  urethral  inflammation  will  beat- 
tended  by  its  rheumatism,  in  spite  of  all  efforts  to  keep  it  off.  Fortu- 
nately, all  patients  with  gonorrhoea  are  not  liable  to  this  complication 
— a  small  minority  only  is  affected.     An  ordinary  patient  with  gon- 

*  For  bibliography,  see  "  Art  Medical,"  Xovcmbcr  and  December,  1837,  vol.  vi.  "Ob- 
servations et  Materiaux  pour  servir  il  THistoire  de  rArthropatliic  blennorrhagique,"  Ch. 
Ravel,  and  Fournier,  art.  "  Diet,  de  Med.  et  de  Chir.  Prat." 

f  "  Ueber  die  Sogcnannten  metastatiscbcn  Complicationen  der  Gonorrhoea,"  etc.,  "  In- 
aug.  Dissert.,"  Berlin,  1873. 


GONORRHCEAL  RHEUMATISM.  ^7 

orrhoea,  even  having  a  pronounced  rheumatic  diathesis,  may  expose 
himself  to  cold,  moisture,  and  fatigue,  without  getting  any  rheuma- 
tism ;  or,  if  ho  does  get  an  attack,  its  course  is  not  varied  nor  its 
symptoms  modilied  by  the  coexistence  of  urethral  discharge. 

This  fact  of  individual  idiosyncrasy  favors  the  reflex  nervous  rather 
than  the  pyemic  theory  of  etiology. 

Women  possess  a  strange  immunity  from  gonorrho3al  rheumatism. 
They  do  sufl'er  from  it,  but  only  exceptionally.  It  is  supjoosed  that 
the  explanation  for  this  may  be  found  in  the  fact  that  the  vagina  and 
not  the  urethra  is  the  usual  seat  of  gonorrhoea  in  the  female. 

Gonorrhoeal  rheumatism  resembles  rheumatic  gout  more  than  rheu- 
matism. The  local  inflammatory  character  of  the  symptoms  is  usually 
inconsiderable,  and  the  constitutional  sympathy  is  not  of  a  severity 
proportionate  to  the  trouble  in  the  joints. 

The  date  of  appearance  of  the  rheumatic  complication  from  the  be- 
ginning of  the  urethral  discharge  is  variable.  It  has  been  noticed  as 
early  as  the  fifth  day,  but  usually  does  not  come  on  till  a  later  period. 
Fournier  places  the  usual  date  of  the  outbreak  between  "  the  sixth 
and  fifteenth  day,"  rarely  during  the  second  or  third  month,  or  at  any 
later  period.  The  old  idea,  that  the  rheumatic  complication  is  the 
result  of  a  metastasis  of  the  gonorrhoea,  is  untenable.  There  is  no 
diminution  of  the  discharge  ]Drevious  to  or  coincident  with  the  inva- 
sion of  the  rheumatism,  and  there  exists  no  indication  to  increase  the 
urethral  flow  and  thus  "save  the  synovial  membranes."  The  dis- 
charge is  not  usually  at  all  modified,  although  it  is  sometimes  notably 
diminished  a  few  days  after  the  rheumatic  symptoms  have  set  in — 
which  may  be  explained  by  the  fact  that  the  rheumatism  keeps  the 
patient  more  at  rest,  or  by  the  revulsive  action  which  any  interven- 
ing inflammatory  affection  is  liable  to  exercise  over  a  purulent  dis- 
charge. Where  the  complication  comes  on  late  in  a  clap,  it  has  been 
observed  that  its  advent  is  preceded  by  an  exacerbation  of  the  dis- 
charge for  a  few  days. 

The  seat  of  the  disease  is  variable — joints  taking  the  first  rank  ;  the 
synovial  sheaths  of  tendons  and  muscles  the  second  ;  then  coming  syno- 
vial bursce  and  nerves.  The  eye  not  infrequently  suffers.  The  peri- 
cardium (Brandes)  and  meninges  of  the  brain  and  cord  (Eicord)  seem 
to  be  involved  occasionally.  Concerning  the  joints,  Fournier  tabulates 
one  hundred  and  twenty  cases,  of  which  thirty-nine  are  his  own.  The 
whole  number  of  joints  affected  in  these  cases  was  two  hundred  and 
twelve;  the  knee,  eighty-three  times  —  over  two  thirds  of  all  the 
cases ;  ankle,  thirty-two  times — about  one  fourth  ;  fingers  and  toes, 
twenty-five  times — about  one  fifth,  etc.  Eecently  Fournier  *  places 
the  seat  of  predilection  in  the  sterno-clavicular  articulation.    The  large 

*  "  Gaz.  Hebd.,"  November  16,  ISTJ.     Discussion  before  Hospital  Society  on  Desnos's 
case  of  Konorrhoeal  endocai'ditis. 


88  COMPLICATIONS  OF   GOXOKRHCEA. 

joints,  particularly  the  knee,  are  by  far  the  most  often  involved,  and, 
when  the  smaller  joints  suffer,  they  do  so  couseeutively.  The  disease 
IS  rarely  absolutely  confined  to  a  single  joint ;  but  still  it  shows  a 
marked  tendency  to  be  mono-articular.  Fouruier's  division  of  the 
disease  into  three  prominent  varieties  is  convenient  and  practical. 

The  first  form — a  common  one — is  a  hydrarthrosis,  attacking 
usually  the  knee,  sometimes  the  ankle  or  elbow.  This  form  is  gener- 
ally mono-articular.  It  comes  on  insidiously  ;  but  the  elTusion  into 
the  joint,  which  is  usually  considerable,  may  take  place  rapidly.  The 
pain  is  slight,  but  is  increased  by  walking,  running,  or  moving  the 
joint.  There  may  not  be  enough  pain  to  call  the  patient's  attention 
to  his  joint,  although  this  is  unusual.  The  integument  over  the 
affected  region  preserves  its  color,  and  there  may  be  no  constitutional 
disturbance.  The  affection  tends  to  remain  indolent,  and  to  undergo 
resolution  slowly,  lasting  sometimes  many  months. 

The  second  form  is  more  like  ordinary  rheumatism.  More  or  less 
local  and  general  febrile  reaction  is  the  rule,  and  this  form  is  usually 
poly-articular  and  liable  to  be  attended  by  trouble  in  the  tendons, 
eyes,  etc.  The  symptoms  are  like  those  of  ordinary  rheumatism,  only 
more  moderate.  The  pain,  at  first  severe,  is  usually  notably  modified 
by  rest — far  more  so  than  is  the  case  with  ordinary  rheumatism.  Con- 
stitutional symptoms  occur ;  but  the  fever  is  moderate,  and  subsides 
after  a  few  days,  while  the  local  disturbance  continues.  This  relative 
lack  of  proportion  between  the  constitutional  and  the  local  symi^toms 
is  a  strong  diagnostic  feature  of  the  malady  in  question.  When  only 
one  joint  is  affected,  there  is  sometimes  a  total  absence  of  general 
symptoms.  When  several  joints  are  involved,  they  become  so,  as  a 
rule,  consecutively.  The  malady,  however,  docs  not  become  so  gen- 
eral as  it  does  in  ordinary  rheumatism.  It  is  more  stationary,  less 
mobile,  docs  not  jump  from  one  joint  to  another.  When  a  new  joint 
is  involved,  those  previously  affected  continue  to  suffer — with,  of 
course,  occasional  exceptions.  Eesolution  is  even  more  tardy  than  in 
ordinary  rheumatism.  A  secondary  hydrarthrosis,  rare  in  simple 
rheumatism,  is  not  uncommon  in  the  gonorrhojal  variety.  The  sweat- 
ing, so  constant  in  simple  rheumatism,  docs  not  occnr,  even  where 
there  is  a  good  deal  of  fever,  or,  if  it  does  come  on,  it  is  of  short  dura- 
tion. The  acid  concentrated  state  of  the  urine,  found  in  simple  rheu- 
matism, is  not  noticed,  nor  does  the  blood  show  the  same  excess  of 
fibrin.  Finall}',  tlie  pericardium,  endocardium,  pleura3,  etc.,  are 
rarely  involved.  Cardiac  affections  due  to  gonorrhosii  arc  recorded  by 
several  reliable  authorities.* 

*  Baud  in,  "Receuil  de  Mem.  de  Med.  de  Cliir.  et  de  Pliarm.  Mil.,"  September  and 
October,  1875.  Marty,  "  Archiv.  Gen.  de  Med.,"  1876,  p.  660.  Desnos,  "  Gaz.  Hebd.," 
November  16,  1877.  Morel,  "  Thbsc  dc  Paris,"  1878.  Floury,  "Journ.  de  M6d.  de  Bor- 
deaux," September  9,  1883, 


GONORRnffiAL   RHEUMATISM.  39 

Slow  resolution  is  the  usual  termination  of  the  disease,  but  articu- 
lar pains,  or  very  persistent  stiffness,  may  be  left  behind ;  or,  more 
rarely,  chronic  hydrarthrosis,  chiefly  of  the  smaller  ariiculations 
(Brandes),  anchylosis,  or  even  white  swelling — the  latter  only  in  lym- 
phatic or  scrofulous  patients  (Sordet).  Acute  suppuration  does  not 
occur  (Fournier). 

The  third  form  which  the  affection  may  assume  is  that  of  vague, 
ambulatory — sometimes  very  persistent — pains  in  Joints,  which  do  not 
appear  to  have  suffered  any  structural  alteration,  and  of  which  the 
function  is  undisturbed — the  knee,  wrist,  shoulder,  foot,  and  jaw. 
This  pain,  which  may  be  the  only  symptom,  is  rebellious  to  treatment, 
and,  after  it  has  gradually  subsided,  is  opt  to  return,  if  from  any 
cause  the  amount  of  urethral  discharge  becomes  increased. 

The  synovial  sheaths  of  the  tendons  of  the  extremities  may  be 
affected,  either  alone,  or,  more  commonly,  in  connection  with  what- 
ever joints  are  involved.  There  are  tumefaction  along  the  course  of 
the  tendon,  redness  of  the  integument,  occasionally  very  intense,  if 
the  tendon  be  superficial,  severe  pain  on  pressure,  and  partial  or  entire 
abolition  of  the  movement  of  the  muscle  belonging  to  the  tendon  in- 
volved. This  affection,  like  the  others,  undergoes  gradual  resolution. 
Hot  local  anodyne  fomentations  are  indicated. 

The  bursas  may  also  suffer.  In  this  case  we  have  an  acute  or  sub- 
acute hygroma,  which  is  peculiarly  painful  and  sensitive  to  pressure 
for  a  long  time.  Two  bursae  seem  most  liable  to  the  attack,  the  one 
lying  between  the  tendo  Achillis  and  the  os  calcis,  and  the  other  situ- 
ated beneath  the  inferior  tuberosity  of  the  same  bone.  This  explains 
the  pain  in  the  heel,  so  often  complained  of  by  these  patients — al- 
luded to  by  Swediaur.     Other  bursge  suffer,  but  more  rarely. 

The  acute  symptoms  accompanying  inflammation  of  bursse  usually 
yield  rapidly  to  local  depletion  and  sedatives  ;  later  a  blister.  Fonr- 
nier  mentions  a  case  of  gonorrhoeal  hygroma  of  a  bursa  over  the  is- 
chium, which  he  saw  with  Yerneuil.  The  symptoms  attending  it 
were  so  severe  as  to  lead  these  gentlemen  to  a  diagnosis  of  deep  suppu- 
ration. They  made  preparations  to  incise  the  swelling,  when  a  sharp 
pain  suddenly  appeared  in  the  knee.  The  operation  was  postponed. 
In  a  few  days  the  hygroma  disappeared  '^with  surprising  rapidity," 
while  the  knee-joint  became  acutely  inflamed. 

Evidences  of  muscular  rheumatism  may  attend  the  symptoms  of 
rheumatic  trouble  elsewhere.  The  nerves  do  not  always  escape. 
Fournier  observed  sciatica  five  times  among  his  thirty-nine  cases. 
Diplopia  (Fournier),  deafness  (Swediaur,  Fournier),  and  little  super- 
ficial collections  of  sernm  near  the  affected  joints  (Fournier,  Eicord, 
Fereol),  have  been  mentioned  as  rare  occasional  complications.  The 
following  excellent  table,  arranged  by  Fournier,  gives  at  a  glance  the 
characters  distinguishing  gonorrhoeal  from  ordinary  rheumatism  : 


90 


COMPLICATIONS  OF  GOXORRH(EA. 


Gonorrhteal  JUtevmatism. 

1.  Cause. — Urethral  intlanimation.  Xo 
influence  of  cold  in  the  production  of  the 
rheumatism. 

2.  Very  rarely  observed  in  women. 

3.  Non-febrile,  or  much  less  so  than  sim- 
ple rheumatism.  Even  in  acute  cases,  reac- 
tion never  attains  the  habitual  intensity  of 
rheumatic  fever. 

4.  Symptoms  habitually  limited  to  a 
small  number  of  joints.  The  affection 
never  becomes  general  to  the  same  extent 
as  simple  rheumatism. 

5.  Less  movable  than  simple  rheuma- 
tism, going  from  one  joint  to  another  less 
quickly.  No  delitescence,  no  real  jumping 
from  one  joint  to  another. 

G.  Local  pains  generally  moderate,  al- 
ways less  than  in  simple  rheumatism. 
Sometimes  remarkable  indolence. 

7.  Frequently  a  tendency  to  hydrarthro- 
sis, following  the  acute  fluxion. 

8.  No  sweatiug. 

9.  Urine  not  modified. 

10.  Blood  not  furuiihing  a  marked  bufCy- 
coat. 

]  1.  Cardiac  complications  very  excep- 
tional. 

12.  Frequent  coincidence  with  a  special 
ophthalmia,  inflammation  of  the  synovial 
sheaths  of  tendons,  inflammation  of  bur- 
sa?, etc.  The  latter  localities  may  be  ex- 
clusively implicated. 

13.  Relapse  in  the  course  of  successive 
gonorrhoeas  very  frequent. 


Simj}k  lihcumatism. 

1.  No  etiological  relation  with  the  state 
of  the  urethra.  Habitual  causes — cold,  in- 
heritance, rheumatic  diathesis,  etc. 

2.  Common  in  the  female,  although  less 
frequent  than  in  the  male. 

3.  Rcactional  phenomena  much  more  in- 
tense and  prolonged  than  in  gonorrha^al 
rheumatism. 

4.  Svmptoms  usually  involve  a  number, 
sometimes  nearly  all,  the  articulations. 


5.  Symptoms,  movable  —  ambulatory 
fluxions ;  rajjid  delitescence,  jumping  from 
one  joint  to  another. 

C.  Pains  always  rather  intense,  some- 
times excessive,  disappearing  less  rapidly 
than  those  of  gonorrhoeal  rheumatism. 

*?.  Little  or  no  tendency  to  consecutive 
hydrarthrosis. 

8.  Abundant  sweats,  constituting  a  symp- 
tom almost  essential  to  the  malady. 

9.  Urine  specially  modified. 

10.  Blood  forming  a  firm,  concave  clot 
with  buff_y-coat. 

11.  Cardiac  complications  frequent. 

12.  Acute  rheumatism  does  not  affect 
the  eye ;  the  bursa;  escape,  as  do  usually 
the  sheaths  of  tendons. 


13.  Relapse  frequent,  but  always  inde- 
pendently of  the  state  of  the  urethra. 


Treatment. — Ordinary  treatment  for  acute  or  chronic  rheumatic 
or  gouty  maladies  does  not  help  patients  with  gonorrhceal  rheumatism. 
Neither  salicylic  acid  nor  iodide  of  potassium,  colchicum,  nor  quinine 
modify  the  symptoms.  Local  measures  are  of  the  first  importance. 
The  treatment  internally  is  tonic,  dietetic,  hygienic — in  short,  rational 
— with  an  alkali  if  the  urine  is  over-acid.  The  sooner  the  urethral 
discharge  is  controlled  the  more  quickly  will  the  rheumatic  symp- 
toms cease,  although  the  latter  may  outlast  the  former  many  months. 
Eest  is  most  important,  the  joint  being  splinted  in  the  acute  stage. 
Leeches,  hot  fomentations,  or  a  blister  will  soon  bring  on  the  sub- 
acute stage,  if  indeed  the  inflammatory  phenomena  have  not  been 
subacute  from  the  first.  The  diet  should  be  low  while  the  patient  is 
confined.     Probably  the  best  treatment  in  acute  and  subacute  cases 


GONORRIKEAL   OPIITHALMIA.  91 

is  rest,  blistering  or  Paquclin  cautery  freely  applied  and  often  re 
peated  ;  in  chronic  cases  where  there  is  effusion,  iodine,  with  the 
elastic  bandage,  or  sometimes  a  silicate  bandage — the  latter  particu- 
larly in  obstinate  cases  —  or  aspiration  of  the  joint  and  irrigation 
with  a  mild  carbolic-acid  two-per-cent  solution,  or  a  solution  of 
the  bichloride  of  mercury  (1  in  10,000),  followed  by  gentle  systematic 
pressure,  the  joint  remaining  fixed.  In  chronic  cases  and  for  articular 
and  muscular  pains,  blistering,  actual  cautery,  rubber  bandage,  local 
douche,  friction,  massage,  Russian  and  Turkish  baths,  render  valuable 
service.  Recently  R.  W.  Taylor  *  claims  phenomenal  success  in  acute 
cases  from  the  use  of  ten-to-twenty-drop  doses  of  oil  of  wintergreen 
four  times  a  day. 

GONORRHCEAL    OPHTHALMIA. 

There  are  two  forms  of  ocular  trouble  caused  by  gonorrhoea.  The 
first  is  rheumatic  in  charactei-,  nearly  always  (Ricord,  Fournier),  but 
not  invariably,  accompanied  by  other  signs  of  gonorrhoea!  rheumatism, 
having  no  connection  with  contagion  as  a  cause,  and  affecting  the 
membrane  of  Descemet,  the  iris,  or  the  conjunctiva. 

The  second  form  is  conjunctivitis,  depending  always  upon  conta- 
gion. The  distinction  between  these  two  affections  should  be  kept 
constantly  in  view. 

Rheumatic  Gonokrhceal  Ophthalmia. — To  Abernethy,  Mac- 
kenzie, and  particularly  Ricord,  is  due  the  credit  of  having  first  accu- 
rately described  this  affection.  It  is  generally  associated  with  the 
poly-articular  variety  of  gonorrhoeal  rheumatism.  It  may  precede  or 
follow  the  development  of  rheumatism  elsewhere.  Contagiou  will 
not  produce  it.  Its  essential  cause  is  the  existence  of  a  urethral  dis- 
charge. According  to  Fournier,  it  is  more  frequent  than  gonorrhoeal 
conjunctivitis,  as  14  to  1 ;  cold,  fatigue  of  the  eye,  etc.,  have  no  power 
to  produce  it.  An  individual  idiosyncrasy  seems  to  preside  over  its 
appearance.  Should  it  occur  with  one  urethral  inflammation,  the 
chances  are  that  it  will  reappear  with  the  next.  It  is  far  more  com- 
mon in  the  male  than  in  the  female.  Sometimes  it  appears  to  exer- 
cise a  revulsive  action  upon  the  joint  trouble,  and  vice  versa,  the  one 
disappearing  to  be  replaced  by  the  other,  but  this  is  exceptional.  In 
brief,  gonorrhoeal  ophthalmia  is  a  localization  of  gonorrhoeal  rheuma- 
tism upon  the  eye,  all  the  rest  of  the  body  (perhaps)  escaping. 

Symptoms. — Inflammation  of  tlie  memhrane  of  Descemet  (aquo-cap- 
sulitis)  is  the  most  common  form  of  attack.  Here  the  conjunctiva 
is  only  moderately  injected,  the  cornea  is  transparent,  but  more  than 
usually  prominent.  A  cloudy,  smoky  appearance  of  the  fluid  of  the 
anterior  chamber  is  the  most  characteristic  objective  symptom.    Sight 

•*  "New  York  Medical  Journal,"  June  4,  1887,  p.  617. 


02  COMPLICATIONS  OF  GOXORRHCEA. 

is  slightly  troubled,  objects  looking  misty.  There  is  no  pain,  but 
sometimes  a  sensation  of  uneasiness  about  the  eye.  Photoj^hobia  is 
absent  or  yery  mild.  Sometimes  tliere  is  a  slight  flocculcnt  deposit 
on  the  posterior  face  of  the  cornea,  with  the  escape  of  a  little  blood 
into  the  aqueous  humor  (Cullerier).  The  iris  is  unaffected,  perhaps  a 
little  slow  in  its  moyements.  There  is  no  deformity  of  the  pupil,  no 
change  in  color  of  the  iris,  no  otlier  sign  of  iritis — points  strongly  in- 
sisted on  by  Cullerier.* 

When  the  i)'is  is  attacked,  the  symptoms  do  not  differ  from  those 
of  simple  iritis  ;  redness  of  the  cornea,  radiate  peri-corneal  injection, 
contracted  deformed  pui)il,  sluggishness  or  abolition  of  the  move- 
ments of  tlic  iris,  change  of  color,  effusion  of  lymjih  into  the  pupil, 
plastic  deposits  in  the  anterior  chamber,  more  abundant  in  gonorrhceal 
than  in  ordinary  iritis  (Mackenzie),  obscurity  of  yision.  pliotophobia, 
lachryma*:ion,  peri-orbital  and  ocular  pains, 

Fournier  has  described  a  rare  conjunctival  form  of  (jonorrhceal 
ophthalmia.  There  are  simple  conjunctivitis,  injection  of  the  con- 
junctiva, uniform,  or  marked  at  certain  points — the  secretion  is  scanty, 
muco-purulcnt.  There  are  slight,  perhaps  no  lachrymation,  a  little 
itching  about  the  eyes — sometimes  absolutely  no  pain,  i)hotophobia,  or 
alteration  of  vision,  no  symptom  of  iritis  or  of  aquo-capsulitis. 

These  varieties  of  ophthalmia,  unlike  the  contagious  conjunctivitis, 
are  rarely  mono-ocular ;  when  so,  the  form  is  usually  iritis.  Both 
eyes  are  rarely  attacked  simultaneously.  After  one  has  recovered,  in- 
flammation may  attack  the  other,  run  its  course,  and  then  return  to 
the  eye  first  involved.  To  get  the  disease  the  patient  liimself  must 
have  gonorrhoea,  unlike  the  conjunctivitis  of  contagion,  which  may 
be  produced  in  any  healthy  individual  by  the  mere  contact  of  gonor- 
rhceal  pus. 

Gonorrhoea!  ophthalmia  runs  a  rapid  course,  declining  with  un- 
usual Sliced.  It  may  last  several  weeks,  or  only  a  few  days.  Eelapse 
is  not  infrequent..  Of  the  three  forms,  conjunctivitis  is  the  least 
harmful,  aquo-capsulitis  is  not  grave  ;  the  iritis  alone  is  lia)jle  to  leave 
trouble  behind  in  the  shape  of  adhesions. 

Treatment  is  mainly  expectant.  The  eye  must  bo  kept  at  rest  in 
all  cases.  The  best  local  applications  are  emollient  lotions  and  col- 
lyria  frequently  used,  warm  water  or  steam — with  atropine,  in  case  of 
iritis.  Astringent  collyria  are  useless,  even  harmful.  Irritating 
pediluvia,  the  judicious  use  of  revulsive  cathartics,  and  a  low  diet,  con- 
stitute the  general  treatment.  If  the  symptoms  prove  obstinate,  tlie 
frequent  application  of  small  mild  blisters  to  the  temples  and  forehead 
is  of  service.  In  mild  cases,  patients  do  better  if  not  confined.  They 
may  even  attend  to  business,  if  the  eye  be  kept  covered.     In  severe 

*  "  Des  Affections  blennorrhagiqucs."  Le9on3  cliniques  publid'cs  par  Eug5nc  Royet, 
Paris,  1861. 


GONORRUffiAL   CONJUNCTIVITIS.  93 

cases,  housing  is  necessary,  local  emissions  of  blood  may  ho  practiced, 
and  repeated  purgation  should  be  resorted  to.  AVhen  the  peri-orbital 
and  frontal  pains  arc  severe  in  iritis,  large  doses  of  quinine  seem  to  be 
of  service,  with  the  local  inunction  of  belladonna-ointment,  or  of  a 
liniment  composed  of  ol.  menth.  pip.  four  parts,  chloroform  and  liq. 
ammonias,  of  each  one  part ;  or — 

R   Chloroform,  tr.  opii,  ol.  oliv.,  a.i  q.  a.     M. 

If  the  pains  persist,  in  spite  of  these  measures,  codeine  or  mor- 
phine may  be  used  at  night,  by  the  stomach,  or  subcutaneously. 

GoisroRRHCEAL  CoiSTJUNCTiviTis. — This  terrible  malady  is  fortu- 
nately rare.  Its  sole  and  only  cause  is  contact  of  gonorrhceal  pus 
with  the  conjunctiva.  It  has  no  other  relation  with  gonorrhoea  than 
this,  and  may  affect  the  surgeon  or  the  nurse  as  well  as  the  patient, 
provided  only  a  little  of  the  contagious  pus  touch  the  conjunctiva. 
Hence  the  necessity  of  forewarning  patients  of  the  danger  they  run 
in  neglecting  the  most  scrupulous  cleanliness  of  the  hands  after  dress- 
ing the  penis,  using  injections,  or  passing  water.  For  the  surgeon, 
this  precaution  is  equally  necessary,  together  with  the  other  one  of 
burning  all  pieces  of  si3onge,  linen,  lint,  etc.,  which  are  brought  into 
contact  with  gonorrhceal  pus,  derived  either  from  the  urethra  or 
the  eye.  If  this  be  neglected,  the  subsequent  use  of  the  sponge  on  a 
healthy  eye  may  carry  the  contagion  to  it,  and  give  rise  to  a  dangerous 
malady. 

This  disease  is  truly  a  gonorrhceal  conjunctivitis,  and  is  easily  sepa- 
rable from  gonorrhceal  ophthalmia,  a  disease  impossible  upon  a  given 
subject  unless  he  is  at  the  same  time  himself  suffering  from  urethral 
inflammation.  The  so-called  sympathetic  (metastatic)  gonorrhceal 
ophthalmia  is  of  the  latter  variety,  and  should  never  be  confounded 
with  true  contagious  conjunctivitis. 

Gonorrhceal  conjunctivitis  is  rare  ;  of  37,034  cases  of  disease  of  the 
eyes  treated  at  the  New  York  Eye  Infirmary,  it  occurred  59  times, 
once  in  628  cases  (Bumstead).  It  is  much  more  frequent  in  the  male 
than  in  the  female,  on  account  of  the  greater  opportunities  for  conta- 
gion. The  right  eye  suffers  more  often  than  the  left,  since  most  pa- 
tients handle  the  .penis,  and  rub  the  right  eye,  with  the  right  hand. 
Penanguer  *  states  the  proportionate  occurrence  of  the  disease  in  the 
eyes  to  be  four  times  in  the  right  to  once  in  the  left. 

The  symptoms  are  those  of  purulent  conjunctivitis  intensified. 
Tlie  rapidity  with  which  the  symptoms  aggravate  is  often  appalling. 
The  slight  dry,  sandy  feeling  attending  the  first  congestion  of  the  eye 
is  of  the  shortest  duration,  as  is  the  secretion  of  tears  and  muco-pus. 
Within  a  few  hours  after  contagion  the  discharge  is  frankly  purulent, 
and  the  inflammatory  symptoms  go  on  increasing  rapidly  in  severity, 

*  "De  rOphthalmie  blennorrhagique."     These,  Paris,  1851. 


Q-j.  COiirLICATIONS   OF   GOXOKREffiA. 

until,  iu  three  or  four  days,  often  sooner,  destrnction  of  sight  is  inev- 
itable. Sometimes  the  safety  of  the  eye  is  compromised  in  a  few 
liours  (ten  to  twelve).  The  vessels  of  the  conjunctiva  rapidly  fill 
with  blood,and  its  tissues  become  distended  with  serum  (chemosis). 
The  border  of  the  infiltrated  conjunctiva  overlaps  and  partly  conceals 
the  cornea,  the  latter  lying,  as  it  were,  at  the  bottom  of  a  cup  filled 
with  pus.  The  eyelids  have  an  erysipelatous  redness,  are  very  o-dcm- 
atous,  and  swollen.  The  upper  overrides  the  lower.  There  is 
spasm  of  the  orbicular  muscle.  Pus  is  retained  in  large  quantities. 
Pain,  ocular  and  peri-orbital,  is  often  intense.  The  cornea  soon  falls 
jnto  ulceration,  if  the  chemosis  continue.  There  is,  first,  a  imrulent 
infiltration  between  its  lamellre,  then  softening  and  ulceration,  suj^er- 
ficial  at  first,  and  usually  situated  near  the  circumference  of  the  cor- 
nea, perhaps  obscured  from  casual  inspection  by  the  overhanging, 
chcmosed  conjunctiva.  This  ulceration  jDrogresses  rapidly  to  perfora- 
tion, the  aqueous  humor  escapes,  perhaps  hernia  of  the  iris  occurs. 
The  cornea  may  be  pressed  out  into  an  anterior  staphyloma,  or  be  de- 
stroyed by  the  ulcerative  jiroccss,  or  fall  out,  as  a  whole,  like  a  watch- 
glass,  allowing  the  contents  of  the  eye  to  escape.  The  general  symp- 
toms are  moderate.  Fever  is  usually  mild,  except  in  rare  cases  of 
suppuration  of  the  globe,  and  soon  gives  place  to  a  nervous,  depressed, 
irritable  condition,  attended  by  insomnia,  agitation,  inquietude,  more 
rarely  stupor. 

Diagnoais. — The  following  table,  prepared  by  Fournier,  sets  forth 
the  distinguishing  characteristics  of  the  two  ocular  affections  liable 
to  be  found  upon  a  patient  with  a  urethral  discharge.  The  distinc- 
tions can  not  be  too  strongly  insisted  upon,  on  account  of  the  liability 
to  confusion  of  two  conditions,  one  of  which  is  so  harmless  and  so 
little  benefited  by  remedies,  the  other  so  destructive  and  so  positively 
under  the  control  of  treatment.  The  specific  gonococcus  always 
abounds  in  the  pus  of  gonorrhoeal  conjunctivitis — is  absent  in  gonor- 
rhoeal  ophthalmia. 

Gonorrhoeal  Conjunctivitis.  Gonorrhccal  Ophthalmia. 

1.  Essential  cause — inoculation  of  the  1.  Contagion  plays  no  part  in  the  pro- 
conjunctira  with  gonorrhoeaf  pus.                      duction  of  the  malady,  which  is  developed 

under  the  influence  of  an  internal  cause,  the 
nature  of  which  is  unlcnown. 

2.  A  rare  affection.  2,  An  inf  rc(iuent  complication  of  gonor- 

rhoea, but  still  much  more  common  tlian  the 
contagious  ophthahnia  : :  14  :  1. 
.3.  May  affect  subjects  not  suffering  from         3.  Only  attacks  patients  already  suffcr- 
gonorrhoea.  ing  from  gonorrlioea. 

4.  Usually  only  one  eye  involved.  4.  Commonly  both  eyes. 

5.  The  symptoms  are  those  of  the  grav-  5.  The  symptoms  arc  those  of  an  inflam- 
est  kind  of  purulent  ophthalmia.  They  af-  mation  of  the  membrane  of  Dcscemet,  of  an 
feet  the  conjunctiva  primarily.                          iritis,  or  of  an  oculo-palpebral  conjunctivitis. 


GONORRIICEAL   CONJUNCTIVITIS— TREATMENT.  95 

Gonorrhceal  Conjundivilin — ( Continued).  G'onorrhoeal  OjAlhalmia — (Continued). 

6.  Symptoms  fixed,  not  going  from  one  0.  SomctimcH  the  inflainmatoiy  phenom- 

eye  to  the  other.  cna  are  mobile,  pa.s.sing  from  one  eye  to  the 

other. 
v.  No  tendency  to  relapse  in  subsequent         1.  Frequent   relapses  in  the  course  of 

gonorrhojas.  subsequent  gonorrhwas. 

8.  No  coincidence  with  rheumatic  mani  8.  Coincidence  with  gonorrhfcal  rheu- 
fcstations.  matism  very  habitual,  almost  constant. 

9.  Prognosis  excessively  grave.     Often         9.  Prognosis  without  gravity, 
loss  of  the  eye. 

10.  The  eye  is  only  saved  by  a  most  10.  Expectation,  or  the  simplest  treat- 
energetic  treatment.  ment,  sufficient  for  a  cure. 

Prognosis. — When  a  severe  purulent  conjunctivitis  develops  in  an 
individual  with  a  urethral  discharge,  or  even  in  a  friend,  especially  if 
any  history  of  contagion  can  be  elicited,  the  prognosis  is  most  grave. 
Unless  an  energetic  treatment  be  instituted,  the  eye  is  lost,  and,  if  aid 
come  a  little  late,  some  lesion  of  greater  or  less  severity  and  affecting 
vision  is  pretty  sure  to  remain  behind.  Fortunately,  both  eyes  are 
rarely  involved. 

Treatment. — There  is  not  a  moment  to  be  lost.  Delay  may  sacri- 
fice the  eye.     The  essentials  of  treatment  are  four  : 

1.  Eelief  of  tension. 

2.  Eelief  of  chemosis. 

3.  The  early  free  repeated  use  of  a  strong  cauterant. 

4.  Cleanliness. 

Each  of  these  four  is  about  equally  important. 

The  greatest  care  is  necessary  in  handling  the  tender,  swollen  eye. 
No  pressure  is  allowable.  The  dressings  should  be  the  lightest  pos- 
sible— even  the  pressure  of  the  swollen  lids  upon  the  eye  is  prejudicial, 
and  must  be  met  by  early,  free  canthojolasty  at  the  external  angle,*  an 
operation  to  be  repeated  if  necessary.  All  the  dressings  should  be  per- 
formed by  a  skilled  hand,  else  they  will  be  inefficient.  The  utmost 
care  should  be  used  in  protecting  the  sound  eye  from  contagion.  It 
may  be  hermetically  sealed  with  lint  and  collodion  where  the  nurse  is 
not  trustworthy.  Old  soft  rags  are  most  suitable  for  wiping  off  the 
discharges,  and  these  should  be  destroyed  at  once  by  fire.  The  pus 
retains  its  contagious  properties  for  hours  after  it  has  dried,  and  fresh 
pus  has  been  found  to  be  still  contagious  when  diluted  with  one  hun- 
dred parts  of  water.  The  rapid  and  virulent  nature  of  the  inflamma- 
tion occasioned  by  the  contagion  of  gonorrhceal  pus  has  been  amply 
demonstrated  by  certain  oculists,  who  have  treated  pannus  by  inocu- 
lating the  eye  with  this  material  for  the  purpose  of  exciting  an  acute 
inflammation. 

If  the  patient  is  seen  early,  before  his  symptoms  hare  run  high, 

*  Critchett  ("Lancet,"  April  3,  1880,  p.  62i)  in  one  case  in  a  child  had  to  slit  the 
upper  lid  vertically  to  the  brow  in  order  to  expose  the  cornea.     The  eye  was  saved. 


90  COMPLICATIONS   OF   GOXORRHOEA. 

and  before  the  secretion  is  frankly  i)urulent — within  the  lirst  twenty- 
four,  at  most  forty-eight  hours — if  he  is  robust,  it  is  advisable  to  take 
three  or  four  oimces  of  blood  from  the  temple,  or  mastoid  i)rocess  of 
the  affected  side,  by  leeches  or  cups.  If  the  effect  seem  favorable,  this 
local  bloodletting  may  be  repeated  in  ten  or  twelve  hours,  and  even  a 
third  time  if  necessary.  Irritant  purgatives,  and  a  low  diet  at  first, 
are  of  advantage.  Perfect  rest  of  body,  and,  if  jiossible,  of  mind, 
should  be  secured.     The  sick-room  should  be  obscurely  lighted. 

If  the  patient  is  Jiot  robust,  not  an  ounce  of  blood  can  be  spared,  a 
laxative  rather  than  a  cathartic  should  be  given,  while  the  diet  must 
be  nourishing  and  supportive,  even  stimulating  if  there  be  much  de- 
pression. Under  no  possible  circumstances  is  a  mercurial  course  ad- 
visable, or  a  continued  depressing  treatment  harmless. 

The  local  treatment  is  the  same  for  all  cases.  If  the  patient  is  seen 
very  early,  iced  water  is  to  be  applied  locally  upon  a  thin  fold  of  cloth, 
which  must  be  constantly  changed.  As  soon  as  pus  begins  to  form,  a 
solution  of  gr.  x  to  xx  of  nitrate  of  silver  should  be  iiuiuted  over  the 
conjunctiva,  and  the  iced  water  continued.  Every  few  hours  the  eye 
must  be  reiusjjccted,  and  the  nitrate-of-silver  solution  reapplied.  As 
pus  begins  to  form  more  abundantly,  or  if  the  patient  is  not  seen  until 
suppuration  is  profuse,  the  strength  of  the  solution  must  be  increased 
up  to  3  j  to  the  3  j,  or  the  solid  stick  may  be  employed,  being  care- 
fully drawn  over  the  entire  ocular  and  palpebral  conjunctiva.  The 
cornea  is  of  course  spared  in  ai)plying  the  caustic.  After  using  strong 
solutions  of  the  nitrate  of  silver,  the  excess  should  be  washed  away 
with  a  solution  of  common  salt. 

The  object  of  these  powerful  apjilications  is  to  restrain  the  forma- 
tion of  pus  and  change  the  discharge  into  a  sero-sanguinolent  one. 
They  should  be  made  sufficiently  often  and  sufficiently  strong  to  pro- 
duce this  effect.  The  iced-water  compress  should  be  kept  up  for  a 
number  of  hours  after  each  application,  then  the  lids  should  be 
anointed  with  cold  cream,  and  left  uncovered,  simply  shaded  from  the 
light.  Cauterization  should  be  repeated  whenever  the  discharge  gets 
abundant  and  thickly  purulent.  Free  use  of  cocaine  somewhat  lessens 
the  pain  of  the  cauterizations. 

The  water  or  cerate  will  keep  the  outside  of  the  eye  reasonably 
clear,  but  the  swelling  of  the  lids  and  spasm  of  the  orbicular  muscle 
tend  to  confine  much  of  whatever  discharge  there  may  be.  Hence  the 
value  of  canthoplasty.  It  allows  dressings  to  be  made  easily,  prevents 
the  ball  from  suffering  pressure  (thus  contributing  to  preserve  the 
cornea),  and  makes  cleanliness  easy.  The  outer  canthus  should  be 
continued  by  an  incision  down  to  the  bone.  A  skilled  nurse  from 
time  to  time  should  gently  separate  the  lids,  and  scpiceze  a  few  drops 
of  warm  water  into  the  eye  from  a  soft  rag,  removing  all  external  pus 
with  the  same  cloth.     A  syringe  should  not  be  used  to  wash  the  eye. 


GONORRHOEAL   COXJUNCTIVITIS— TREATMENT.  97 

for  fear  of  spattering.  A  mild  solution  of  nitrate  of  silver,  gr.  v  to  x, 
is  sometimes  of  advantage,  dro^jped  into  the  eye  between  the  cau- 
terizations. The  treatment  must  be  continued  unremittingly,  the 
eye  being  washed,  dressed,  and  inspected  every  two  or  three  hours, 
until  the  symptoms  abate.  An  anodyne  may  be  required  to  pro- 
duce sleep. 

Chemosis  is  treated  by  extensive  and  deep  scarifications  performed 
with  the  curved  bistoury  or  scissors.  These  scarifications  must  be 
thorough.  They  should  never  be  made  before,  always  after  a  cauteri- 
zation, otherwise  the  surgeon  will  have  to  wait  some  time  for  hsemor- 
rhage  to  cease,  or  he  will  not  apply  his  cauterization  thoroughly,  and, 
furthermore,  an  unnaturally  hardened  condition  of  the  conjunctiva  is 
liable  to  be  left  behind  by  the  healing  of  the  scarifications,  the  surfaces 
of  which  have  been  cauterized  down  to  the  bottom.  Some  of  the  che- 
mosed  conjunctiva  may  be  snipped  away,  but  deep  scarification  with  a 
bistoury,  often  repeated,  is  better. 

When  the  cornea  becomes  opaque,  use  atropine  at  once,  and,  with- 
out waiting  for  ulceration,  puncture  the  anterior  chamber,  repeating 
this  operation  as  often  as  the  cornea  becomes  tense.  It  is  better  to  do 
this,  especially  if  there  be  ulceration,  than  to  run  the  risk  of  hernia  of 
the  iris,  or  possible  escape  of  the  contents  of  the  globe. 

Peri-orbital  pains  are  combated  as  are  those  of  gonorrhoeal  oph- 
thalmia. 

When  the  acuteness  of  the  symptoms  begins  to  subside,  milder 
astringent  collyria  may  take  the  place  of  the  nitrate  of  silver  ;  such  as — 

5     Alum  exsic,  gr.  vj-xij  to  the  §  j. 

or — 

5     Zinci  sulph.,  gr.  j  iij       "    "      " 

or — 

^     Sodfe  biborat.,  gr.  v-x       "    "      " 

These  may  be  applied  to  the  eye  by  means  of  any  of  the  ingenious 
'■'droppers"  which  the  shops  afford,  or,  if  the  patient  can  slightly 
open  and  close  the  lids,  he  may  diffuse  the  solution  over  his  eye  by 
throwing  back  the  head  until  the  plane  of  the  face  becomes  horizontal, 
then  closing  both  eyes,  and  dropping  a  little  of  the  solution  (not  too 
cold)  over  the  inner  canthus  of  the  one  to  be  medicated.  Now,  by 
several  times  rapidly  opening  both  eyes  to  their  widest  extent  and  then 
shutting  them,  the  fluid  enters  the  eye  and  circulates  over  the  globe. 
This  method  does  not  succeed  with  strong  solutions,  causing  pain,  and 
should  not  be  used  with  solutions  which  stain  the  skin.  Xitrate  of 
silver  should  always  be  applied  by  an  experienced  hand,  and  be  brought 
into  contact  with  every  portion  of  the  conjunctiva. 

The  inflammation  once  reduced  to  a  subacute  state,  tends  to  get 
well  slowly.  The  discharge  drags  along  on  an  average  for  from  two 
to  four  weeks — often  longer.  In  these  cases  blisters  behind  the  ears, 
1 


98  STRICTURE   OF   THE   URETHRA. 

on  the  temples,  seton  at  the  nucha,  etc.,  have  been  recommended, 
together  with  plenty  of  good  food,  fresh  air,  tonics,  stimulants,  etc. 

Granular  conjunctivitis  and  anterior  staphyloma  may  be  mentioned 
as  not  very  rare  complications  of  gonorrhanil  conjunctivitis. 


CHAPTER  V. 

STRICTURE  OF  TUE   URETHRA. 

Definition. — Varieties:  Mnscnlar,  Organic— Organic  Stricture.— Form. —Number.— Seat. —  The 
Lesion  in  Stricture. —  Causes.- Time  of  Occurrence  of  Stricture. —  Irritable  and  Resilient 
Stricture. 

An  unnatural  narrowness  of  any  portion  of  the  canal  of  the  urethra 
constitutes  stricture  ;  or,  since  the  urethra  is  naturally  a  shut  canal, 
Sir  diaries  Bell's  definition  may  be  more  accurate,  and  any  loss  of 
dilatability  may  be  termed  stricture.  This  contraction  of  the  canal, 
following  the  first  definition,  to  constitute  stricture,  must  be  unnat- 
ural, for  the  urethra  has  certain  points  of  normal  contraction — namely, 
the  meatus,  the  middle  of  the  pendulous,  and  the  beginning  of  the 
membranous  urethra,  and  these  are  not  strictures.  They  become  so, 
however,  if  they  are  unduly  small.  Thus,  an  individual  with  an  aver- 
age-sized penis  and  urethra,  whose  meatus  will  only  take  No.  10  F., 
has  stricture  (congenital)  of  the  meatus,  although  he  may  never  suffer 
any  inconvenience  therefrom.  Again,  any  inflammatory  condition  of 
the  walls  of  the  canal,  or  spasmodic  contraction  of  the  same,  consti- 
tutes stricture,  as  does  also  any  growth  upon  or  beneath  the  mucous 
membrane — cancerous,  tubercular,  syphilitic,  membranous. 

A  collection  of  fluid  outside  the  canal  may  constitute  stricture — 
abscess,  serous  or  hydatid  cyst,  etc. — anything,  in  short,  which  lessens 
the  size  of  the  canal  when  distended  by  the  stream  of  urine,  foreign 
bodies,  of  course,  excepted.  In  all  the  last-named  conditions,  how- 
ever, stricture  is  only  an  epiphenomenon,  and  not  the  disease  itself. 

In  this  section,  pure  stricture  only  will  be  discussed. 

Stricture  is  of  two  kinds  :  1.  Muscular,  or  spasmodic.  2.  Perma- 
nent, or  organic — the  latter  congenital,  or  acquired.  Inflammatory 
stricture  does  not  exist  as  a  disease  of  the  urethra.  The  smallest 
amount  of  inflammation  will  lessen  the  caliber  of  the  canal,  just  in 
proportion  to  the  amount  of  turgescence  of  the  mucous  membrane  ; 
but  this  is  unimportant.  No  amount  of  simple  inflammation  of  the 
urethral  mucous  membrane  gives  rise  to  enough  diminution  of  the  size 
of  the  canal  to  occasion  serious  inconvenience  (retention),  unless  occur- 
ring in  connection  with  organic  stricture,  assisted  by  muscular  spasm 
or  complicated  by  prostatic  congestion.     A  croupous  membrane  may 


MUSCULAR   OR   SPASMODIC   STRICTURE.  Of) 

exist  within  the  urethra,  and  obstruct  more  or  less  the  flow  of  urine  ; 
but  this  is  exceedingly  uncommon.  Eokitansky*  speaks  of  "very 
rare  cases"  where  "we  find  primary  croup  occurring  on  the  urethral 
mucous  membrane  " — this  chiefly  in  children.  Membranous  deposits 
may  occur  upon  the  surface  of  organic  stricture,  or  behind  it ;  but 
these  are  not  to  be  confounded  with  true  croup. 

1.  Muscular  or  Spasmodic  Stricture. — Spasmodic  stricture  is 
of  the  commonest  occurrence  ;  an  active  joredisposing  cause  is  a  sensi- 
tive, high-strung  nervous  organization,  often  in  connection  with  an 
irritable,  gouty,  or  rheumatic  constitution,  and  particularly  in  those 
who  are  sexually  astray.  The  exciting  causes  are  any  local  irritation, 
inflammation,  foreign  body,  irritation  of  the  rectum  (reflex  action), 
ingestion  of  certain  substances,  cantharides,  turpentine,  quinine,  opi- 
um, etc.,  mental  emotions,  malaria.  The  seat  of  contraction  is  in  the 
unstriped  muscular  fibers  which  surround  the  urethra  at  the  irritated 
point  (stricture,  foreign  body),  or  at  the  membranous  urethra  in  the 
voluntary  "  cut-off  "  muscle.  Verneuil  f  believes  that  spasmodic  strict- 
ure, due  to  urethral  (reflex)  irritation,  is  situated  in  the  membranous 
urethra,  while  spasm  due  to  irritation  above  the  vesical  neck  (also 
reflex)  has  its  seat  in  the  posterior  yesical  sphincter  of  unstrij)ed  mus- 
cle. Eobin  and  Cadiat  J  believe  that  urethral  spasm  is  always  situ- 
ated in  the  unstriped,  never  in  the  voluntary,  muscles  ;  but  the  case 
they  give  in  proof  is  hardly  demonstrative. 

The  action  of  many  of  these  causes  may  be  readily  illustrated. 
Take  a  nervous,  excitable  young  man  with  a  healthy  urethra — a  forti- 
ori, with  an  irritable  bladder  or  inflamed  urethra — and  attempt  to  pass 
a  bougie  for  the  first  time,  and  the  chances  are  that  it  will  be  arrested. 
It  may  be  grasped  and  firmly  held  at  any  part  of  the  canal,  but  this 
is  more  liable  to  occur  just  as  the  instrument  is  entering  the  mem- 
branous urethra,  where  its  point  may  be  detained  for  many  minutes 
by  an  involuntary  contraction  of  the  cut-off  muscles.  If  the  end  of 
the  sound  is  held  quietly  for  a  few  moments  against  the  contracting 
muscle,  the  spasm  will  yield,  and  the  instrument  pass  on  into  the 
bladder.  Any  foreign  body  in  the  urethra  is  liable  to  excite  this 
amount  of  spasm  around  it.  If  any  portion  of  the  canal  is  in  a  state 
of  irritation,  especially  if  slight  organic  stricture  exist  (this  is  a  potent 
cause  of  spasm),  some  contraction  is  almost  certain  to  take  place  at 
this  point  on  the  approach  of  an  instrument,  and  to  recur  after  the 
sound  has  passed  along,  giving  the  sensation  of  "grasping"  or 
"biting"  upon  the  instrument,  which  is  so  well  marked  in  most 
strictures. 

The  spasm  caused  by  cantharides  is  attended  by  a  good  deal  of 

*  "Sydenham  Translation,"  vol.  ii,  p.  235. 

f  Sebeaux,  "  Contracture  du  Col  de  la  Vessie,"  Paris,  18*76,  p.  S2. 

X  "Journal  de  I'Anat.  et  de  la  Physiol,"  September,  IS'74,  p.  531. 


100  STRICTURE   OF   TIJE   URETHRA. 

congestion  as  well.  It  is  styled  straniiurv — a  term  too  well  known  to 
require  further  comment. 

AVhat  surgeon  has  not  witnessed  spasmodic  stricture,  caused  hy 
modesty,  shame,  anxiety,  fear,  irritated  mind  (Cooper,  Sebeaux),  as 
shown  by  the  total  inability  of  some  patients  to  pass  water  before  a 
class  of  students  or  even  in  the  presence  of  a  physician  alone  in  his 
office  ?  In  such  cases  there  is  not  a  failure  of  the  detrusor  urina?  to 
contract,  but  there  is  a  failure  of  the  compressor  urethrae  to  relax. 
The  patient  contracts  his  abdominal  muscles  and  his  diaphragm,  and 
uses  all  his  will,  but  to  no  purpose.  Let  the  surgeon  now  gently 
introduce  a  well-warmed  and  oiled  catheter  of  medium  size  into  the 
bladder,  and  the  spirt  that  will  follow,  as  soon  as  its  eye  touches  urine, 
will  easily  convince  him  that  there  is  no  fault  to  find  with  the  con- 
traction of  the  detrusor.  The  latter  muscle,  however,  al.<o  shares  in 
producing  the  phenomenon,  as  when  a  young  man  holds  his  water  too 
long  in  company,  and  at  last  upon  an  opportunity  finds  he  has  reten- 
tion. In  such  a  case  a  soft  catheter  passes  unobstructed,  but  the  first 
part  of  the  urinary  flow  will  be  very  feeble  from  atony  of  the  detrusor. 
There  are  two  cases  on  record  (Thompson  and  B.  Brodie)  of  malarial 
spasm  where  spasmodic  stricture  occurred  paroxysmally  every  twenty- 
four  or  forty-eight  hours,  and  was  cured  by  quinine  after  other  means 
had  failed. 

As  instances  of  spasmodic  stricture  from  neighboring  irritation  and 
reflex  action  may  be  cited  retention  coming  on  suddenly  in  connection 
with  inflamed  haemorrhoids  after  operations  near  the  anus,  especially 
where  the  sphincter  ani  has  not  been  paralyzed  by  section  or  stretch- 
ing ;  retention  occurring  with  irritable  ulcer,  or  even  from  worms. 
Thompson,  quoting  Tuffnell,  gives  a  case  where  all  the  symptoms  of 
stricture  existed,  and  where  a  diagnosis  of  stricture  of  the  membranous 
urethra  was  made,  when  it  was  discovered  that  the  patient  had  tape- 
worm. The  latter  w^as  treated,  and  after  the  worm  had  been  dis- 
charged the  stricture  and  its  symptoms  disappeared.  Emmet  had  a 
case  where  a  necrosed  coccyx  occasioned  urethral  spasm,  and  Verneuil 
one  where  abscess  of  the  right  seminal  Aesicle  caused  spasmodic  strict- 
ure of  obstructive  character  (Sebeaux).  I  have  seen  complete  reten- 
tion caused  in  a  healthy  young  man  (whose  urethra  had  never  been 
inflamed)  by  one  application  of  the  tincture  of  dcli)hinium  to  the 
scrotum  to  destroy  pediculi.  A  soft  catheter  passed  once  relieved  him, 
and  he  remained  well. 

Dartigues  *  alludes  to  a  number  of  remotely  situated  surgical  lesions 
as  occasioning  retention  by  reflex  spasmodic  stricture,  as  forward  luxa- 
tion of  the  hip,  mentioned  by  Hippocrates,  Malgaigne,  Cooper,  and 
others,  five  cases  after  amputation  of  the  thigh,  three  after  ablation 
of  the  breast,  one  after  breaking  up  an  anchylosis  of  the  elbow. 

*  "These  dc  Doctorat,"  Paris,  1873. 


MUSCULAR   OR  SPASMODIC   STRICTURE.  101 

Otis  calls  prolonged  urethral  spasm  urethrismns.  Under  this  nnmo 
F.  H.  Davenport*  records  the  case  of  an  old  man  who  had  all  the 
evidences  of  permanent  dec])  urethral  obstruction  for  ten  years,  and 
who  was  relieved  at  once  and  permanently  by  a  single  passage  of  a 
silver  catheter.  If  in  this  case  the  meatus  had  been  freely  incised, 
and  the  catheter  then  passed  into  the  bladder,  the  cure  might  very 
naturally  have  been  ascribed  to  the  cutting  operation,  although  the 
latter  would  have  no  share  (really)  in  the  cure,  as  the  case  proves. 

I  have  met  a  large  number  of  cases  in  which  spasmodic  stricture 
was  more  or  less  strongly  marked,  the  cause  of  the  reflex  spasm  being 
(1)  a  decidedly  narrow  meatus,  or  a  strictured  anterior  urethra  (but 
this  very  rarely)  ;  I  believe  I  have  never  met  deep  urethral  spasm  Avhicli 
I  considered  due  to  anterior  stricture  of  large  caliber  alone  ;  (2)  very 
moderate  organic  stricture,  or  mild  surface  irritation  of  the  mucous 
membrane  at  the  bulbo-membranous  junction  (this  is  most  common)  ; 
(3)  various  emotional  causes,  cutaneous  irritation,  rectal  lesions,  vari- 
ous organic  changes  in  the  seminal  vesicles,  in  the  prostate,  bladder, 
and  (very  often)  the  kidney.  I  have  seen  it  of  most  intense  and  per- 
sistent type  in  a  case  of  abscess  connected  with  disease  of  the  bodies 
of  the  lumbar  vertebrae,  and  quite  often  in  oxaluric  patients  with  neu- 
ralgia of  the  deep  urethra. 

Strongly  concentrated  acid  urine  may  occasion  spasmodic  stricture 
in  a  gouty  individual,  attended  by  more  or  less  congestion — perhaps 
positive  inflammation — and  this  all  the  more  readily  if  there  be  a  small 
amount  of  organic  stricture. 

Certain  forms  of  lumbar  neuralgia  coincident  with  painful  spas- 
modic contraction  of  the  urethra  have  been  described  by  Neucourt.f 

Indeed,  there  are  so  many  different  conditions  which  are  recog- 
nized as  being  a  possible  cause  of  deep  urethral  spasmodic  stricture 
that  it  seems  strange  that  this  affection  is  not  even  more  common  than 
we  actually  find  it  in  practice. 

DiAGisrosis. — Spasmodic  stricture  always  occurs  suddenly,  the  stream 
of  urine  between  the  paroxysms  being  of  normal  size.  It  is  occasion- 
ally continuous,  and  acts  exactly  like  organic  stricture,  disappearing 
only  with  a  removal  of  the  cause.  Otis  has  recorded  some  unusual 
cases  of  this  variety^  This  difference  is  sufficient  to  distinguish  it 
from  organic  stricture  where  the  stream  is  permanently  small. 

Treatment  consists  in  the  discovery  and  removal  of  the  cause,  pay- 
ing special  attention  to  sexual  irregularities,  the  gouty  diathesis,  con- 
centrated urine,  and  points  of  congestion,  or  commencing  organic  strict- 
ure in  the  urethra.  Eetention  produced  by  simi^le  spasm  can  often  be 
relieved  by  the  hot  bath,  rest,  and  an  opiate,  ice  in  the  rectum,  or  at 
once  by  an  anaesthetic  and  the  catheter.     Belladonna  seems  powerless. 

*  "Boston  Medical  and  Surgical  Journal,"  May  12,  ISSl,  p.  4-44. 

f  "De  la  Nevralgic  Lombaire,"  etc.,  "  Arcbiv.  Gen.,"  July,  1S5S,  p.  21. 


102 


STRICTURE   OF   THE   URETHRA. 


Fig.  25  (YoUlemur). 


Permanent  or  Organic  Stricture. — Congenital  stricture  has 
been  described  {see  Atresia).  In  this  section  we  have  to  do  with  or- 
ganic stricture,  the  result  of  a  previous  pathological  process. 

Form  of  Stricture. — All  strictures  may  be  ranged  under  three 
heads :  {a)  linear,  [b)  annular,  {c)  tortuous. 

(rt)  Linear  Stricture. — Here  the  strict- 
ure is  like  what  would  be  caused  if  a  thread 
were  tied  around  the  canal  (Fig.  25) ;  or 
it  may  consist  of  a  thin  membranous  dia- 
phragm, with  its  orifice  at  the  center  or  on 
one  side  ;  or  be  a  crescentic  fold  or  free 
band,  encircling  the  urethra  entirely  or  par- 
tially in  a  transverse  or  oblique  direction. 
It  is  single  or  multiple. 

{h)  Annular  Stricture. —  This  form  is 
broader,  as  if  a  flat  tape  had  been  tied 
around  the  canal  (Fig.  26).  The  term  is 
applied  to  strictures  not  over  a  quarter  of 
an  inch  long. 

(c)   Tortuous  or  Irregular  Stricture. — 
Here  all  other  varieties  come  in.     Such  a  stricture  may  be  an  inch  or 
more  long — even  the  whole  pendulous  urethra  may  be  in  a  hardened, 
stiffened,     narrowed 
condition. 

The  amount  of 
contraction  in  strict- 
ure varies  from  an 
almost  imperceptible 
narrowing  of  the 
canal  to  nearly  abso- 
lute occlusion,  so 
that,  after  death,  it 
may  be  impossible 
to  introduce  even  a 
bristle  through  it. 
Absolute  occlusion 
does  not  occur  ex- 
cept after  the  canal 
has  been  severed  by 
an  injury,  and  the 
urine  has  found  an 
escape  through  the 
wound  ;  or  where 
numerous  large  fist- 
ulas have    long    ex- 


FiG.  2G  (DUtel). 


SEAT   OF   STRICTURE.  103 

isted,  giving  exit  to  all  the  urine.  The  urethra  in  front  of  a  strict- 
ure always  continues  pervious,  whether  urine  pass  through  it  or  not ; 
although,  from  lack  of  habitual  distention,  its  walls  are  liable  to 
become  somewhat  rigid,  sensibly  diminishing  the  normal  proportions 
of  the  canal. 

Number  of  Strictures. — Stricture  is  usually  single.  Out  of  two 
hundred  and  seventy  preparations,  showing  stricture,  found  in  the  mu- 
seums of  Loudon,  Edinburgh,  and  Paris,  Thompson  *  found,  in  two 
hundred  and  twenty-six  cases,  solitary  stricture.  Hunter  found,  in  a 
single  urethra,  six  ;  Lallemand,  seven  ;  Colot,  eight ;  Leroy  d'Etiolles, 
eleven,  and  Otis  fourteen.  Thompson  has  seen  three — at  most  four — 
and  believes  that  if  more  are  found  they  must  be  considered  as  irregu- 
lar contractions  of  the  same  stricture. 

Seat  of  Stricture. — Upon  this  subject  the  laborious  investiga- 
tions of  Thompson,  upon  the  two  hundred  and  seventy  specimens 
above  referred  to,  must  be  considered  final,  especially  as  daily  expe- 
rience with  patients  bears  out  the  truth  of  his  conclusions.  He  divides 
the  urethra  into  three  regions  : 

1.  IMie  bulbo-membranous,  including  one  inch  in  front  of  and 
three  quarters  of  an  inch  behind  the  junction  of  the  spongy  with  the 
membranous  urethra. 

2.  From  the  anterior  limit  of  region  one,  to  within  two  and  one 
half  inches  of  the  meatus,  embracing  from  two  and  one  half  to  three 
inches  of  the  spongy  urethra. 

3.  The  first  two  and  one  half  inches  of  the  canal  from  the  meatus. 
The  two  hundred  and  seventy  preparations  showed  three  hundred 

id  twenty  strictures. 

Kegion  1  contained  215  strictures — 67  per  cent. 
"      2        "  51         "  16      " 

"      3         "  54        "  17      •■' 

There  were  185  cases  of  one  stricture  only,  situated  in  region  1. 

<(  a         -j^iy       a  ii  li  te  a  o 

a  a         24       "  "  '^  "  "  3 

Otis  places  a  majority  of  all  strictures  within  the  first  one  and  one 
quarter  inch  from  the  meatus — the  next  most  common  position  being 
somewhere  in  the  middle  portion  of  the  pendulous  urethra.  He  be- 
lieves deep  urethral  stricture  to  be  far  less  common  ;  but  these  views, 
which  Dr.  Otis  has  for  years  labored  earnestly  to  advance,  are  largely 
influenced  by  his  theory  that  the  urethra  ought  to  be  a  tube  evenly 
calibrated  throughout,  and  therefore  what  most  other  authors  believe 
to  be  points  of  physiological  narrowing  (perhaps  exaggerated  in  many 
individual  instances)  of  the  normal  healthy  urethra,  he  denominates 
stricture. 

Thompson  did  not  find  in  any  preparation,  or  upon  any  living  pa- 
*  "  Stricture  of  the  Urethra,"  third  edition,  1869. 


104:  STRICTURE   OF   THE   URETHRA. 

tient,  or  in  any  autopsy,  a  prostatic  stricture.  AValsh  *  describes  a 
stricture  in  the  museum  of  the  Royal  College  of  Surgeons,  Dublin,  as 
commencing  in  the  posterior  part  of  the  membranous  and  extending 
into  the  prostatic  urethra,  Leroy  d'Etiollesf  says  that  he  has  in  his 
collection  one  specimen  showing  })rostatic  stricture.  I\icord  J  and 
Civiale*  have  encountered  it,  and  Mastin  ||  makes  the  same  assertion. 
In  brief,  the  situation  of  organic  stricture  is  as  follows  :  Most  fre- 
quently in  the  bulbo-membranous  urethra,  sometimes  as  far  back  as 
the  posterior  part  of  tlie  membranous  ])urtion — that  is,  at  a  distance 
var3*ing  from  four  and  one  half  to  six  and  one  half  inches  from  the 
meatus.  Next  in  the  first  two  and  one  half  inches  of  the  canal,  usually 
just  at  the  meatus,  or  at  the  posterior  limit  of  the  fossa  navicularis, 
and  finally  at  some  intermediate  point  in  the  spongy  urethra.  Pros- 
tatic stricture,  formerly  considered  so  common,  may  be  said  practi- 
cally never  to  occur.  The  frequency  of  stricture  at  the  bulb  and  fossa 
navicularis  is  explained  by  the  greater  vascularity  of  these  portions  of 
the  canal,  and  the  greater  amount  of  erectile  tissue  found  there.  It 
is  well  known  that  gonorrhoeal  inflammation  tends  to  settle  upon  these 
localities  after  the  rest  of  the  mucous  membrane  has  returned  to  its 
normal  condition.  Injury  inflicted  by  the  rough  use  of  the  nozzle  of 
a  syringe,  in  injecting  the  canal,  possibly  has  something  to  do  with 
the  subsequent  formation  of  stricture  near  the  meatus.  Traumatic 
stricture  most  often  invests  the  membranous  urethra,  just  beneath  the 
snb-pubic  ligament.  Both  Otis  and  Gross  believe  that  masturbation 
is  a  very  common  cause  of  stricture. 

The  Lesion  in  Strictuee. — The  morbid  change  in  organic  strict- 
ure may  be  a  mere  thickening  of  the  mucous  membrane,  the  surface  hav- 
ing lost  its  polish,  being  congested,  and  perhaps  covered  with  granula- 
tions. These  changes  are  the  result  of  chronic  inflammation,  and  re- 
semble those  which  occur  in  any  tegumentary  structure  of  the  body 
which  is  kept  in  a  condition  of  mild  chronic  inflammation  ;  namely, 
there  is  a  proliferation  of  cellular  connective-tissue  elements,  and  a 
consequent  proportionate  increase  in  the  thickness,  density,  and  in- 
elasticity of  the  membrane.  This  process  takes  place  just  within  and 
beneath  the  mucous  membrane,  and  not  on  its  free  surface,  as  shown 
by  A.  Guerin,'^  who  states  tliat,  in  one  hundred  autopsies  of  i)atients 
with  gonorrhoea,  more  than  one  half  of  whom  had  stricture,  he  found 
the  morbid  process  in  these  latter  always  to  have  acted  immediately 
beneath  the  mucous  membrane  and  in  the  spongy  tissue.  If  the 
stricture  is  a  little  more  extensive,  a  few  whitish  transverse  fibers  will 

*  "Dublin  Medical  Press,"  January  26,  1856. 

\  "Des  Retrecisscments  de  I'Urethre,"  Paris,  184.5,  p.  83. 

X  "Notes  to  Hunter  on  Venereal,"  second  edition,  Philadelphia,  18.59,  p.  168. 

*  "  Maladies  des  Organcs  genito-urinaires,"  second  edition,  Paris,  1850,  vol.  i,  p.  158. 
I  "Boston  Medical  and  Surgical  Journal,"  1879,  p.  878. 

^  "  Des  Retr(5cissements,  etc.,"  "  Mem  de  la  Soc.  de  Chir.,"  vol.  iv,  1857,  p.  125. 


CAUSE   OF   STRICTURE.  105 

be  found  encircling  the  caiiul,  beneath  the  mucous  membrane.  If 
more  advanced  still,  the  meshes  of  the  spongy  tissue  will  be  found 
glued  together,  obliterated,  and  a  mass  of  dense,  fibrous,  callous  ma- 
terial encircling  the  canal  and  holding  it  permanently  contracted. 
This  tissue  may  be  slight  in  extent,  cicatricial  in  character,  tightly 
contracted,  or  it  maybe  exuberant,  knobbed,  and  excessive  in  amount, 
so  that  it  may  be  readily  felt  from  the  outside  of  the  canal,  having 
a  cartilaginous  or  even  woody  hardness.  In  this  callous,  fibrous  mass, 
the  microscope  detects  no  yellow,  elastic  fibers — fibers  which  Robin 
and  Cadiat  have  shown  have  such  a  large  preponderance  in  the  healthy 
mucous  membrane  of  the  urethra. 

Flaps,  valves,  and  free  bands,  adhesions,  etc.,  are  formed  by  atro- 
phy of  follicles,  or  of  portions  of  submucous  tissue  ;  or  the  bands  may 
be  caused  by  the  use  of  instruments  in  the  canal — perforating  a  flap, 
for  example. 

Cause  of  Steicture. — Omitting  congenital  and  other  varieties  of 
stricture  already  alluded  to  (cancerous,  etc.),  organic  stricture  is 
always  caused  by  inflammation  or  a  traumatism.  Inflammation  of  the 
urethra  is  the  most  common  cause,  whether  this  be  simple  urethritis 
or  gonorrhoea  ;  but  the  latter  is  far  oftener  followed  by  stricture,  and 
that  simply  because  the  inflammation  is  more  severe  and  more  con- 
tinued. Of  two  hundred  and  twenty  cases  of  stricture  studied  criti- 
cally by  Thompson,  one  hundred  and  sixty-four  (seventy-five  per  cent) 
owed  their  origin  to  gonorrhcea.  The  longer  the  duration  of  a  given 
gonorrhoea  the  more  certain  it  is  to  be  followed  by  stricture.  This  is 
almost  surely  the  case  where  gonorrhoea  prolongs  itself  indefinitely  in 
the  gleety  stage,  the  latter  condition  being  nearly  conclusive  proof  of 
forming  stricture.  Gonorrhoea  attended  by  chordee  is  more  apt  to  be 
followed  by  stricture  than  are  those  cases  where  this  complication  does 
not  exist.  Should  the  chordee  be  "broken,"  stricture  becomes  inevi- 
table, and  that  too  of  the  traumatic  sort.  Anything  connected  with 
urethral  inflammation  which  indicates  that  the  morbid  process  has  ex- 
tended outside  of  the  mucous  membrane,  and  has  invaded  the  delicate 
meshes  of  the  erectile  tissue  around  the  canal,  warns  us  of  coming 
stricture.  The  plastic  exudation,  as  it  is  called,  once  effused,  glues 
the  meshes  of  erectile  tissue  permanently  together,  and  the  cell-prolif- 
eration, starting  with  the  urethral  inflammation,  goes  on  after  the 
latter  has  ceased,  making  new  fibroid  material,  of  which  the  tendency 
is  steadily  and  more  and  more  to  contract.  Cicatricial  tissue  manifests 
this  tendency  to  contract  and  obliterate  the  canal  even  more  stronglv 
than  the  tissue  formed  by  cell-proliferation  after  inflammation.  Lin- 
ear longitudinal  incisions  do  not  occasion  stricture.  Whatever  con- 
traction occurs  in  them,  when  they  unite  without  loss  of  substance, 
being  in  a  longitudinal  direction,  would  tend  rather  to  increase  than 
diminish  the  caliber  of  the  tube  ;  hence  no  strictm-e  follows  operations 


106  STRICTURE  OF  THE  URETHRA. 

for  stone  (properly  performed).  Transverse  incisions,  on  the  other 
hand,  are  always  followed  by  more  or  less  stricture  (Rcybard).*  If 
the  incision  only  just  ojKni  the  canal,  the  amount  of  stricture  will  be 
inappreciable.  If  the  urethra  be  partially  severed,  its  upper  wall  being 
left  intact,  the  contraction  and  subsequent  stricture  will  be  only  par- 
tial, proportionately  to  the  degree  of  section,  and  retention  from  such 
a  stricture  might  never  occur.  When,  however,  the  whole  canal  is 
divided  across,  then  stricture,  going  on  steadily  to  retention,  is  inevi- 
table. Thus  we  may  have  a  traumatic  stricture  giving  scarcely  any  or 
indeed  no  symptom,  and  detected  only  by  accident  during  a  careful 
examination,  although  this  is  so  rare  as  to  be  nearly  hypothetical. 
For,  even  if  only  a  portion  of  the  floor  of  the  urethra  be  cut  across, 
yet  the  upper  wall  rarely  escapes  bruising,  or  injury  of  some  sort, 
which  may  involve  it  in  a  chronic  inflammation  and  overgrowth,  caus- 
ing it  to  assist  in  the  formation  of  the  stricture  starting  below.  If  the 
edges  of  a  urethral  wound  slougli  from  any  cause,  the  subsequent 
stricture  is  by  so  much  the  more  considerable. 

Any  injuries  of  the  canal,  involving  loss  of  substance,  produce  strict- 
ure. To  this  class  belong  urethral  chancres  and  ulcerations,  gangrene 
from  crushing  or  following  phlegmonous  erysipelas  or  infiltration,  ul- 
cers produced  by  prolonged  pressure,  stone,  retained  catheter,  etc. 

But  classical  traumatic  stricture,  such  as  it  is  the  rule  to  encounter 
in  practice,  is  formed  most  often  low  down  in  the  canal  (farther  from 
the  meatus  than  strictures  produced  by  clap),  involving  the  membra- 
nous urethra,  and  generally  caused  by  a  crushing  injury  to  the  peri- 
naeum.  The  urethra  in  this  region  is  particularly  exposed  to  contu- 
sions. It  is  fixed  and  can  not  get  out  of  the  way,  and  the  sharp  edge 
of  the  sub-pubic  ligament  has  a  great  deal  to  do  in  the  causation  of 
the  injury. 

The  injuries  which  have  been  reported  as  causing  traumatic  strict- 
ure in  the  periufeum,  with  or  without  a  j^enetrating  wound,  are  innu- 
merable. Among  the  most  classical  may  be  mentioned  falls  from  a 
height,  the  patient  lighting  astraddle  a  beam,  a  chair,  a  stump,  a  man- 
ger, the  limb  of  a  tree,  the  corner  of  any  blunt  object,  a  trunk,  a  box, 
etc.  ;  falls  astraddle  a  fence  while  walking  upon  it,  of  a  wheel  while 
mounting  an  omnibus,  of  the  tongue  of  a  wagon  ;  falls  upon  a  sharj) 
object,  as  a  chisel,  the  breakage  of  a  chamber-pot  upon  wdiich  the  pa- 
tient has  been  sitting  ;  falling  with  one  leg  through  a  hole  in  the  ice, 
or  down  a  coal-hole  in  the  sidewalk  ;  being  thrown  forward  upon  the 
pommel  of  a  saddle,  while  riding ;  fracture  of  the  pelvis,  kicks  in  the 
perinasum  from  man,  woman,  child,  or  beast,  etc.,  ad  infinitum. 
This,  perhaps,  unnecessarily  minute  detail  of  injuries  capable  of  caus- 
ing stricture  is  given,  because  they  are  all  occurring  constantly.  The 
authors  have  seen  cases  from  each  cause,  and  very  many  from  some  of 
*  "Traite  pratique  de  R6tr6cissements  du  Canal  de  Ur^tre."     Argcnteuil  Prize,  1852. 


STRICTURE— DATE   OF   APPEARANCE.  107 

tliem.  They  are  very  liable  to  be  overlooked  by  the  patient  when,  at 
the  time,  they  do  not  give  rise  to  hcemorrhage  or  retention.  The  in- 
jury is  often  slight,  not  causing  much  immediate  disturbance,  and  the 
patient  forgets  it ;  he  never  has  a  gonorrhoea,  perhaps,  and  yet  in  after- 
years  symptoms  of  stricture  come  on,  and  the  canal  is  found  highly  con- 
tracted at  its  membranous  portion  ;  or,  in  trying  to  relieve  retention 
in  fever,  the  physician  finds  his  catheter  unexpectedly  arrested. 

The  only  treatment  of  gonorrhoea  which  may  cause  stricture  is  the 
use  of  injections.  The  nozzle  of  a  syringe,  if  long  or  roughly  used 
against  an  inflamed  mucous  membrane,  may  irritate  it  suthciently  to 
keep  up  local  inflammation,  until  it  becomes  chronic,  and  passes  on  to 
that  cell-proliferation  and  thickening  which  constitute  stricture.  Lin- 
ear strictures  of  the  first  half-inch  from  the  meatus  are  doubtless  often 
caused  in  this  way.  Secondly,  too  strong  injections  may  cause  strict- 
ure, usually  situated  from  two  to  four  inches  down  the  canal,  rarely 
lower.  The  role  of  injections  in  producing  stricture  has  been  doubt- 
less overrated  ;  probably  none  of  the  fluids  ordinarily  used  are  able  to 
occasion  it,  unless  employed  of  very  unusual  strength.  But,  granting 
that  gonorrhoea  alone  is  amply  sufficient  to  cause  stricture,  yet  it  is  a 
singular  coincidence,  to  use  no  stronger  term, 'that  most  patients  pos- 
sessing particularly  tight  resilient  stricture,  not  due  to  injury,  but  yet 
behaving  as  if  they  were  traumatic,  with  a  very  sensitive,  hyperses- 
thetic  urethra  in  front  of  them — that  many  of  these  patients  have  used 
strong  injections  of  the  nitrate  of  silver,  in  attempted  abortive  treat- 
ment, or  with  the  idea  of  "burning  out"  the  disease — injections 
strong  enough  to  bring  blood  freely,  often  to  be  followed  by  several 
hours  of  severe  urethral  j)ain.  As  a  general  rule,  it  may  be  stated  that 
any  injection  strong  enough  to  produce  either  of  these  two  results 
(blood  or  subsequent  prolonged  pain)  is  capable  also  of  originating 
organic  stricture.  The  opinions  of  the  profession  regarding  the  in- 
strumentality of  injections  in  causing  stricture  have  varied.  For- 
merly it  was  believed  that  injections  of  all  sorts  produced  stricture ; 
but  soon  it  was  noticed  that,  although  no  injections  were  emjjloyed, 
still  stricture  continued  to  follow  gonorrhoea.  Then  all  role  of  cau- 
sality was  denied  to  injections,  of  whatever  nature,  and  however  used. 
But  a  pretty  extensive  experience  seems  to  justify  the  placing  of  the 
truth  between  the  two  extremes,  attributing  the  bad  eifects  of  the 
remedy  only  to  its  excessive  strength. 

Time  of  Occurrence  of  Stricture  after  Gonorrhcea  axd  In- 
jury.— Of  the  164  cases  of  stricture  following  gonorrhoea,  tabulated 
by  Thompson,  in  10,  symptoms  appeared  immediately  after  or  dui'ing 
the  attack  ;  71,  within  one  year ;  41,  between  three  and  four  years ; 
32,  between  seven  and  eight  years  ;  20,  between  eight  and  twenty-five 
years.     J.  D.  Hill,*  from  140  cases  of  stricture  from  all  causes,  makes 

*  "An  Analysis  of  140  Cases  of  Stricture  of  the  Urethra,"  London,  1871. 


lOS  STRICTURE   OF   THE   URETHRA. 

the  length  of  the  period,  between  the  cause  and  the  first  symptoms  of 
stricture  noticed,  to  be  :  after  gonorrhoea,  shortest  period  two  years ; 
longest,  thirteen  years — after  urethral  chancre,  shortest  period  ten 
months ;  longest,  three  years — after  injury,  shortest  period  four 
months  ;  longest,  eighteen  months.  The  statement  in  the  latter  table 
of  statistics,  doubtless  literally  correct,  tends  to  mislead.  After  a 
traumatism,  of  the  crushing  kind,  to  the  perina?um,  for  instance,  the 
classical  course  of  events  is  as  follows  : 

From  oedema  and  effusion  of  blood,  at  first,  there  is  more  or  less 
obstruction  to  the  flow  of  urine  ;  perhaps,  if  the  canal  is  severed,  there 
is  retention.  If  the  latter  has  not  occurred,  inflammation  comes  on, 
and  the  size  of  the  stream  is  still  further  diminished.  Now  inflamma- 
tion subsides  and  repair  begins,  and,  with  this  repair,  contraction  goes 
hand  in  hand.  Consequently,  after  a  transverse  or  crushing  wound 
of  the  urethra,  where  repair  begins  stricture  commences.  It  may  not 
manifest  itself  by  retention,  or,  indeed,  by  any  symptom  which  the 
patient  observes  for  four  months  or  for  several  years,  but  it  is  there 
none  the  less. 

If  the  injury  has  been  slighl*,  or  the  canal  only  partly  involved,  no 
appreciable  symptom  may  occur  for  years  (ten  or  twelve),  as  when 
boys  have  been  kicked  at  school,  have  fallen  on  a  fence,  or  been  thrown 
upon  the  pommel  of  a  saddle.  The  point  of  importance  is  this  :  trau- 
matic stricture  comes  early  because  the  violence  causing  it  is  greater 
(usually)  than  the  violence  of  simple  inflammation  of  the  urethra. 
Let  the  violence  be  trifling,  and  the  interval  may  be  exceedingly  long. 

With  this  understanding,  then,  the  deductions  to  be  drawn  from 
the  above  statistics  are  confirmed  by  daily  observation  :  namely,  that 
the  symptoms  of  stricture  appear  earlier  after  a  traumatism  than  after 
gonorrhoBa,  the  date  of  their  appearance  measurably  proportionate  to 
the  extent  of  the  injury,  and  that  the  greatest  divergence  is  noticeable 
after  gonorrhoea.  It  is  totally  exceptional,  however,  for  symptoms  of 
organic  stricture  to  come  on  "immediately  after  or  during  the  attack" 
of  gonorrhoea — as  Thompson  states  occurred  in  ten  of  his  cases — unless 
stricture  existed  previous  to  the  attack,  unnoticed  by  the  patient,  as 
sometimes  undoubtedly  occurs. 

Irritable  axd  Eesilient  Stricture. — A  stricture  is  said  to  be 
irritable  when  it  is  sensitive,  easily  excited  to  inflammation  from  slight 
causes,  rebellious  to  the  use  of  instruments,  fretting  as  it  wore  under 
their  employment.  A  resilient  stricture  (so  named  by  Syme)  is  one 
which,  without  being  necessarily  irritable,  is  elastic,  India-rubber-like, 
contracting  quickly  after  being  dilated,  sometimes  to  an  extent  greater 
than  existed  before  the  use  of  the  dilating  instrument.  Traumatic 
strictures  are  sometimes  of  this  type,  as  are  strictures  following  strong 
injections  of  nitrate  of  silver. 


INSTRUMENTS— BOUGIES.  109 


CHAPTER  yi. 

STRICTURE  OF  THE   URETHRA. 

Instruments  and  their  Use. — Filiform  Boujjies  with  Manoeuvres  alone,  and  as  Guides. — Bongies. — 
Bulbous  Bougies. — Catheters. — Sounds. — Scale. — Advantages  of  Steel  Instruments. — Instru- 
ments for  Divulsion  with  Manoeuvres. — Instruments  for  Internal  Urethrotomy  with  Manceuvres. 
— Perineal  Urethrotomy  with  and  without  a  Guide. — Rectal  Puncture. — Supra-pubic  Puncture. — 
Dieulafoy's  Aspirator. 

Befoee  passing  to  the  diagnosis,  symptoms,  and  treatment  of 
stricture,  it  is  better  at  once  to  describe  the  instruments  to  be  used, 
the  methods  of  manipulating  them,  and  the  operations  in  which  they 
are  employed,  in  order  to  ayoid  endless  repetition. 

Great  mechanical  ingenuity  has  been  displayed  in  the  construction 
of  instruments  for  the  detection  and  treatment  of  stricture.  Such  of 
them  will  be  mentioned  as  are  considered  best  suited  for  these  objects. 
Space  will  not  allow  a  description  of  more  than  the  type  instruments 
of  each  class. 

The  instruments  which  it  is  necessary  for  the  surgeon  to  possess  in 
order  to  be  able  to  meet  the  requirements  of  all  cases  of  stricture  are  : 
different  varieties  of  bougies,  sounds,  and  catheters  with  a  scale ;  in- 
struments for  divulsion,  internal  and  external  urethrotomy,  and  an 
aspirator. 

BOUGIES. 

Filiform  or  Hair-like  Bougies  are  such  as  measure  one  mil- 
limetre or  less  in  diameter — size  No.  3  (one  millimetre  diameter) 
being  the  smallest  size  that  can  be  accurately  measured  on  a  scale- 
plate.  There  are  three  varieties  of  filiform  bougie  :  the  French,  Eng- 
lish, and  whalebone.  They  are  all  made  conical,  narrowing  down  to 
a  fine  point,  and  gradually  increasing  for  an  inch  or  two  until  the  full 
size  of  the  shaft  is  reached.     The  whalebones  are  olive-tipped. 

Whalebone  filiform  bougies  have  displaced  all  others  at  the  present 
date.  The  black  woven  French  filiform  is  still  used  as  a  guide  to  cer- 
tain cutting  urethrotomes  (Maisonneuve),  being  furnished  with  a 
metallic  end  for  the  purpose  of  being  screwed  upon  the  latter.  The 
device  is  not  a  good  one.  The  caps  become  loosened  and  the  bougie 
may  be  left  in  the  bladder.  The  Maisonneuve  urethrotome,  or  any 
other,  can  be  conducted  into  the  bladder  as  well  upon  a  whalebone 
guide  as  following  a  soft  one.  The  yellow  English  filiform  instru- 
ments have  no  especial  value  ;  they  are  a  little  stiffer  than  the  French, 
but  not  as  good  as  the  whalebone. 


no 


STRICTURE  OF  THE  URETHRA. 


Fig.  27 


Soft  filiform  bougies  are  also  constructed  two  feet  long,  to  serve  as 
guides,  by  being  introduced  into  the  bladder,  and  then  threaded 
through  a  soft  French  gum-clastic  catheter  open  at  both  ends  (Fig. 
2T).  Over  such  a  guide  a  catheter  may 
sometimes  be  safely  conducted  into  the 
bladder,  but  a  long  whalebone  does  bet- 
ter. This  is  equivalent  to  the  other  de- 
vice of  a  conical  catheter,  so  arranged  as 
to  screw  into  an  armed  (screw-tipped) 
filiform  bougie  (Fig.  28). 

WiiALEBOXE  Filiform  Bougies  are 
thin,  hair-like  strips  of  whalebone,  very 
smooth,  conical,  with  slightly  bulbous 
points.  By  dipping  them  into  hot  water, 
the  end  may  be  variously  shaped  (an  ex- 
pedient employed  in  difficult  catheterism 
in  the  last  century) — twisted  into  spiral, 
bent  into  zigzag  (Fig.  29),  a  modification 
which  is  of  vast  assistance  in  threading 
tortuous  strictures  and  escaping  false 
routes  and  lacunae.  The  instrument  may 
be  rotated  during  its  passage,  and  its 
point  be  thus  presented  at  different  portions  of  the  cir- 
cumference of  the  canal,  so  as  finally  to  engage  it  in  the 
orifice  of  the  stricture.  These  bougies,  about  two  feet 
long,  are  also  used  as  guides  for  larger  instruments,  not 

by  being  screwed  upon  them,  but  threaded  through 
a  metallic  loop  made  for  the  purpose,  upon  the 
under  side  of  the  instrument  which  they  are  to 
guide — an  adaptation  of  Desault's  principle — the 
latter  being  known  as  "tunneled"  instruments. 
Prof.  William  II.  Van  Burcn  *  originated  this  de- 
vice. These  guides  render  splendid  service  as  con- 
ductors, but  three  cautions  are  necessary  in  their  employment  for 
this  purpose  : 

1.  The  guide  should  be  eighteen  inches  long.  No  cracked,  bent, 
fissured,  or  frayed-out  instrument  should  ever  be  used.  A  short  guide 
serves,  but  less  well. 

2.  In  employing  a  whalebone  as  a  guide,  it  should  be  first  intro- 
duced into  the  bladder,  then  threaded  into  the  instrument  to  be  guided, 
and  the  latter  pushed  gently  down  to  the  strictured  point,  while  the 
whalebone  is  held  stationary  at  the  meatus.  If  force  be  used  here,  the 
slender  guide  may  double  up  and  a  false  passage  be  made  ;  but  this 
may  always  be  avoided  by  gently  and   continuously  retracting  the 

*  Refer  to  note,  page  127,  first  edition  of  this  treatise. 


Fig.  28. 


■\ 


G.TIEMAMN  &  CO 


Fig.  29. 


FILIFORM   WHALEBONE   BOUGIES. 


Ill 


guide,  as  the  conducted  instrument  is  passing  the  dangerous  point, 
and  until  it  reaches  the  bladder.  The  length  of  the  guide  easily  al- 
lows this  to  be  done. 

3.  The  looj)  of  the  instrument  to  be  conducted  should  always  bo 
amply  large,  and  be  smoothed  off  in  front  so  as  to  have  a  rounded  and 
not  a  cutting  edge  ;  and,  if  the  movement  of  extracting  the  guide,  as 
the  tunneled  instrument  is  being  introduced,  can  not  be  performed  as 
above  described,  both  instruments  should  be 
withdrawn  ;  for,  if  the  one  be  pushed  forward 
forcibly,  or  the  other  pulled  back,  there  is  dan- 


FlG.  30. 

ger  of  cutting  off  a  portion  of  the  whalebone  and  leaving  it  in  the  ca- 
nal— an  accident  which  has  occurred  in  very  competent  hands. 

Large  whalebone  bougies,  having  several  inches  of  filiform  tip  and 
then  suddenly  growing 
larger  in  the  shaft,  have 
been  devised  by  E.  A. 
Banks,  of  New  York. 
They  are  equivalent  in 
their  use  to  a  filiform  bou- 
gie and  tunneled  sound. 

Manceuvre  s. — Re- 
garding the  method  of 
introducing  filiform  bou- 
gies, a  few  words  will  suf- 
fice. Their  fine  points 
are  liable  to  catch,  chiefly 
in  the  lacuna  magna,  but 
also  in  any  of  the  nu- 
merous sinuses  of  Mor- 
gagni,  in  any  false  passage, 
or  against  membranous 
bands  and  folds  of  the 
urethra,  in  the  tortuous 
turnings  of  a  stricture,  or 
in  the  softened  reticulat- 
ed membrane  behind  it. 
With  the  whalebone  bou- 
gie— often  with  any  filiform  instrument — these  obstacles  may  be  gen- 
erally surmounted.  There  are  two  special  manoeuvres  for  accomplish- 
ins:  this  : 


*  ~^-'S  ^ 


1^ 


p^^awi^i 


Fig.  31  (Dittel). 

Showing  lactinas  and  false  passages  in  which  the  points  of 

nlif  orm  instruments  are  liable  to  be  caught. 


112 


STRICTURE  OF   THE   URETHRA. 


1.  "When  au  instrument  catches,  partially  withdraw  and  slightly 
rotate  it,  push  ins:  it  forward  while  making  the  rotatory  movement. 
This  device  rarely  fails  in  linally  engaging  th?  instrument  in  tlie  orilice 
of  the  stri&ture,  especially  if  the  tiliform  point  be  bent  or  twisted  in 
any  direction  (spiral  zigzag),  so  that  its  extremity  may  lie  outside  of 
the  axis  of  the  shaft  of  the  instrument. 

2.  An  excellent  method  of  finding  the  orilice  of  a  stricture,  espe- 
cially where  false  passage  exists,  consists  in  cramming  the  urethra  full 
of  filiform  bougies,  engaging  their  points  in  all  the  lacuujB  and  false 
passages,  and  then  trying  them,  one  after  another,  until  that  one  is 
pushed  forward  which  is  presenting  at  the  orifice  of  the  stricture, 
when  it  will  at  once  engage. 

The  use  of  filiform  bougies  in  threading  tight  strictures  is  greatly 
facilitated  by  first  injecting  the  urethra  full  of  warm  oil.  Filiform 
bougies,  intelligently  used,  make  impassable  strictures  the  greatest 
rarities  in  a  surgeon's  practice. 

Bougies. — Of  other  bougies  (not  filiform)  the  French  and  English 
conical  only  need  be  described — the  blunt  are  not  useful,  nor  are  the 
olive-tipped  of  as  much  service  as  the  simple  conical.  French  conical 
bougies  are  black,  woven,  and  covered  with  gum.  They  come  of  all  sizes, 
and  are  necessary  in  the  treatment  of  stricture  up  to  size  13  or  15  (F.). 
The  oliA-e-tip  is  of  advantage  in  the  large,  objectionable  in  the  small 
sizes.  When  choosing  olive-tipped  bougies,  preference  should  be  given 
to  such  instruments  as  are  rather  stiff,  but  have  a  long,  slender,  flexi- 
ble neck,  supporting  the  bulb.     When  held  vertically,  bulb  upmost, 


Fig.  32. 

and  touched  upon  the  olivary  tip,  the  neck  should  yield  at  once  (Fig. 
32,  A).  Such  an  instrument  will  guide  itself  safely  and  override  ob- 
structions. The  olivary  points  found  on  the  English  conical  bougies 
are  useless,  as  far  as  any  advantage  derived  from  the  bulb  is  concerned, 
from  a  neglect  to  make  the  neck  of  the  instrument  flexible  (Fig.  33,  B). 


THE  BULBOUS  BOUGIE. 


113 


Fig.  33. 


English  yellow  bougies  are  smoother  and  stifFer  than  the  preceding. 
They  keep  much  better  in  the  changeable  climate  of  New  York.  All 
of  the  foregoing  instruments  are  introduced  without  a  stylet,  by  sim- 
ple direct  pressure  with  (perhaps)  rotation. 

The  Bulbous  Bougie  {bougie-a-boule)  is  an  instrument 
essentially  necessary  for  the  accurate  diagnosis  of  stricture. 
They  are  found  of  French  and  English  make.  The  latter 
are  stiffer  and  last  longer.  They  consist  of  a  flexible,  woven 
shaft,  headed  by  an  acorn-shaped  extremity,  of  a  diameter 
much  greater  than  that  of  the  shaft.  They  are  sized  accord- 
ing to  the  diameter  of  the  head.  A  set  of  them,  running 
from  5  to  30,  is  required.  Anything  too  tight  for  5  (5  milli- 
metre circumference)  may  be  said,  practically,  only  to  admit 
a  filiform  instrument  (size  3).  In  choosing  bulbous  bougies, 
they  should  be  selected  with  nicely  conical  short  head  and  an 
abrupt  shoulder  (Fig.  33).  Instrument-makers  have  them  of  all  varie- 
ties, with  very  pointed,  even  oval  heads  and  no  shoulders — occasion- 
ally with  two  or  three  bulbs.     These  are  not  useful. 

The  urethrameter  (Otis's)  is  a  very  ingenious  little  in- 
strument, which  is  designed  to  take  the  place  of  a  whole 
set  of  bulbous  bougies,  from  size  20  to  40  (Fig.  34).  By 
turning  the  handle  the  bulb  is  expanded  to  a  size  indicated 
upon  the  register  at  the  handle.  A  rubber  cap  prevents 
its  bars  from  scratching  the  mucous  membrane.  It  is 
especially  useful  in  calibrating  the  urethra  in  its  pen- 
dulous part.  It  is  to  be  introduced  beyond  the  deepest 
point  of  stricture,  screwed  up,  and  then  drawn  forward. 
The  shaft  is  marked  in  inches  and  half-inches,  and  as 
it  is  drawn  out  the  location  and  size  of  various  points 
of  narrowness  of  the  urethra  may  be  read  off  and  located 
at  once.  The  only  objection  to  the  instrument  is  that  it 
causes  more  pain  in  its  use  than  ordinary  bulbous  bougies 
— a  defect  easily  met  by  using  greater  care  in  its  manipu- 
lation, and,  if  need  be,  first  injecting  the  urethra  with 
a  four-per-cent  solution  of  cocaine  hydrochlorate.  The 
urethrograph  *  of  Dr.  Herschel  is  not  an  instrument  to 
be  commended  for  practical  use,  in  my  opinion.  Me- 
tallic bulbs  on  slender  wires  are  better,  equally  durable, 
'  1  and  excellent  for  the  pendulous  urethra  ;  but  the  woven 

^^^  g^  French  instrument  is  more  delicate,  and  the  best  for  all 

cases,  especially  when  the  deep  urethra  is  to  be  explored. 
It  may  be  said  at  once,  of  all  woven  instrunients,  that  the  English 
are  more  durable  and  easier  to  keep  than  the  French.     The  latter  will 
not  stand  the  heat  of  a  New  York  summer,  unless  specially  protected. 

*  "  London  Lancet,"  April  5,  1884,  p.  608. 


lU 


STRICTURE  OF  THE  URETHRA. 


They  soften  and  stick  to  each  other  ami  to  the  case  in  whicli  they  are 
ke]it — thus  becoming  ruined.  This  may  be  prevented  by  dusting  them 
with  French  chalk  or  keeping  them  in  a  cool  place  in  hot  weather. 


CATHETERS. 

Silver  catheters  do  not  wear  out,  and  it  is  well 
to  have  a  case  of  them  on  hand,  of  short  curve,  from 
size  9  to  22.  They  should  be  made  blunt,  not 
conical,  and.  have  a  flattened  wooden  or 
other  handle,  to  facilitate  manipulation, 
marked  with  its  number  on  tlie  side  of 
the  handle  corresponding  to  the  concav- 
ity of  the  curve  of  the  instrument.  The 
handle  should  be  immovable  on  the  shaft, 
at  right  angles  to  the  plane  of  the  curve 
of  the  instrument  (Fig.  35).  No  one 
not  accustomed  to  manage  difficult  cases 
can  use  a  silver  catheter  without  a  guide 
of  a  less  size  than  No.  9  without  risk  of 
false  passage.* 

English  yellow   elastic    catheters   of 
small    sizes,    conical,    without    bulbous 
point,  may  be  useful  in  the  treatment  of 
stricture  where  the  expulsive  power  of 
the  bladder  is  defective.    Three  varieties 
of  French  flexible  catheter  may  be  men- 
tioned :   the   flexible  olivary,  particular 
attention  being  given,  in  choosing  the 
instrument,  to  the  flexibility  of  the  neck 
(Fig.  32,  A)  ;  the  flexible  catheter,  ojoen 
at  both  ends  (Fig.  27)  ;  and  a  flexible  in- 
strument armed  with  a  metallic 
tip,  to  be  screwed  upon  a  filiform 
guide  (Fig.  38).     All  soft  cathe- 
FiG.  35.  ters  should  be  introduced  with- 

out a  stylet  in  ordinary  cases. 
Fine  silver  catheters  may  be  used  with  safety  and 
advantage  in  cases  of  false  passage  and  tight  strict- 
ure only  when  guided — that  is,  with  a  soft  filiform 
guide  screwed  upon  the  tip,  as  in  the  instrument  of  fio.  3g. 

*  Nothing  short  of  fracture  of  the  penis,  where  compression  is  needed,  will  justify  the 
tying  into  the  urethra  of  a  metallic  instrument  for  more  than  a  day  or  two  at  most,  li' 
this  rule  be  neglected,  ulceration  of  the  urethra  is  the  usual  consequence,  the  points  of 
greatest  ulceration  being  at  the  peno-scrotal  angle — under  the  suspensory  ligament — at 
the  meatus  and  in  the  bladder,  where  the  point  of  the  catheter  touches. 


SOUNDS. 


115 


Bnmstead  (Fig.  3G),  or  tunneled  for  a  whalebone  guide,  after  the 
manner  of  ordinary  tunneled  instruments. 


SOUNDS. 

The  most  necessary  instrument  for  the  treatment  of  stricture  is  the 
steel  sound  ;  for,  whatever  means  be  used  to  cure  the  stricture,  rarely 
can  that  cure  be  maintained  in 
the  deep   urethra  without   the 
help  of  the  sound. 
Steel 


sounds 
conical  or  blunt, 
is  well  to  have 
both   kinds,    but 


Fig.  38< 


are 
It 
a  set  of 
the    former 

only  are  necessary.     They  should 

be  made  of  the  short  curve  (page  34), 

that  one  which  is  based  upon  the  natural 

curve  of   the   fixed   part  of    the  healthy 

adult  urethra.     The  hardest  steel  is  used 

in  their  construction.     They  are  capable  of 

a  high  degree  of  polish,  and  are  smoother 

than  any  other  instruments  used  in  the 

urethra,  metallic  or  soft.     The  conical  in- 
struments to  compose  a  set  run  between 

ISTos.  13  and  35  inclusive.     The  conicity 

of  No.  15  runs  through  seven  sizes  (that 

at  its  point  is  No.  9).     The  other  num- 
bers are  proportionately  conically  sized,  33 

being  conical  through  about  thirteen  sizes 

to  its  tip,  the  full  size  being  reached  Just 

at  the  end  of  the  curve.     Larger  sounds 

may  be  required  for  special  occasions,  but 

it  is  not  worth  while  to  have  them  in  the 

ordinary  case,  as  the  few  larger  ones  may  be  best  carried 

around  in  a  special  case  for  use  when  required. 

Blunt  instruments  have  a  spherical  extremity  and  fit 

the  same  aperture  of  the  scale-plate  throughout.  Both  in- 
struments measure  —  shaft  and  curve  —  about  nine 
inches,  the  flattened  handle  two  and  one  half  inches. 
Upon  this  latter  the  number  is  stamped.  Small 
conical  sounds  with  a  tunneled  extremity  are  very 
serviceable,  with  a  whalebone  filiform  bougie  as  a 
conductor  (Fig.  38). 


Fig.  37. 


116 


STRICTURE   OF  THE   URETHRA. 


SCALE. 


The  scale  for  grading  the  sizes  of  instruments  has  never  been  very 
accurately  fixed,  except  in  France.  The  English  scale,  which  has  been 
until  recently  the  favorite  wherever  the  language  was  si)okon,  is  arbi- 
trary and  inaccurate,  varying  so  much  that  instruments  marked  with 
the  same  number  may  be  found  to  diti'or  two  millimetres  in  diameter. 
The  tendency  of  late  years,  in  this  country  as  well  as  in  England, 
has  been  to  adopt  the  French  scale,  simply  because  it  is  fixed  and 
immutable.  The  only  valid  objection  to  this 
scale  is,  that  it  involves  too  many  instruments 
in  a  case  for  the  ordinary  surgeton,  entailing 
needless  expense  in  procuring  them,  and  care 
in  keeping  them  in  order,  with  no  compen- 
sating advantage,  since  loith  conical  instru- 
ments the  increase  in  diameter  of  only  one  third 
of  a  millimetre  for  a  size  is  unnecessarily  mi- 
nute. This  objection  is  after  all  only  a  moder- 
ate one.  The  French  scale  is  now  practically 
adopted  everywhere  —  the  scale  which  makes 
size  1  one  millimetre  in  circumference,  and 
names  all  other  sizes  according  to  their  circum- 
ference in  millimetres.  In  constructing  a  case 
of  sounds,  therefore,  instead  of  having  the  set 
run  from  10  to  21,  American  scale,  as  formerly, 
it  is  as  well  to  run  from  13  to  35  inclusive, 
using  only  every  second  number  to  make  the 
set,  13, 15,  17,  etc.  The  nearly  universal  adoj)- 
tion  of  the  French  scale  by  authors  makes  me 
desire  to  conform  to  custom.  Dr.  Van  Buren 
was  very  tenacious  of  the  American  scale  of 
numbers,  whicii,  indeed,  was  born  in  his  office, 
and  has  been  considerably  used  in  this  country. 
I  think  it  wiser,  however,  now  to  drop  it,  and 
to  fall  into  line  with  the  French  scale. 

The  best  scale-plate  with  which  I  am  ac- 

FiG.  39.  quaintcd  is  the  one  furnished  with  a  triangular 

slot,  marked  so  as  to  give  the  size  in  the  Eng- 
lish, American,  or  French  number  for  any  instrument,  and  also  marked 
off  in  inches  and  millimetres  upon  one  edge  (Fig.  39).  It  makes  a 
very  compact  and  useful  instrument  in  the  present  state  of  confusion 
in  the  numbering  of  urethral  instruments  Avhich  still  prevails  in  this 
country.  French  numbers  indicate  the  circumference  of  the  instru- 
ment. No.  30  is  thirty  millimetres  in  ciz'cumfcrence.  To  make  this 
or  any  French  number  American,  subtract  one  third  :  30  F.  =  (30  — 


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G 

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10 

11 

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15 
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STEEL  VERSUS  SOFT   INSTRUMENTS.  HJ 

10)  20  Am.  And  to  make  an  American  number  English,  subtract 
about  2  :  20  Am.  =  (20  -  2)  18  Eng. 

In  employing  conical  instruments  of  steel  it  should  be  remembered 
that  the  surgeon  has  the  advantage  of  using  a  wedge  as  well  as  a  lever, 
and,  by  carefully  inserting  any  given  conical  steel  instrument  through 
a  stricture,  he  practically  does  (with  less  violence)  the  same  thing  as 
if  he  passed  a  number  of  blunt  instruments,  since  the  conicity  of  the 
sound  runs  through  many  sizes. 

Advantages  of  Steel  Insteuments  for  dilating  Stricture. — 
Since  Thompson,  one  of  the  most  brilliant  minds  connected  with  the 
subject  of  genito-urinary  surgery,  decided  at  one  time  in  favor  of  the 
use  of  soft  instruments  for  dilating  stricture,  a  word  will  be  necessary 
to  state  the  reasons  why  the  authors  of  this  treatise  hold  a  contrary 
opinion.  In  regard  to  facility  of  manipulation,  that  depends  on  prac- 
tice, and  he  will  use  this,  that,  or  the  other  instrument  the  best, 
who  has  used  it  the  most.  Less  harm  can  be  done  with  flexible  than 
with  solid  instruments,  undoubtedly,  and  on  this  account  they  are  to 
be  recommended  for  the  unskilled,  and  for  all,  however  expert,  in  the 
low  sizes — below  No.  13.  In  trained  hands,  however,  the  steel  sound 
is  perfectly  safe  ;  it  is  smoother  than  any  soft  instrument,  and  cer- 
tainly can  be  passed  into  the  urethra  with  less  pain  than  can  any  other 
instrument,  and  is  capable  of  effecting  more  dilatation,  in  the  same 
length  of  time,  with  the  employment  of  less  force.  Steel  instruments, 
made  with  the  curve  and  conicity  already  described,  possess  all  the 
powers  of  the  wedge,  and  of  a  lever  of  the  first  order.  The  surgeon 
holds  the  long  arm,  the  fulcrum  is  a  sliding  one,  situated  at  the  junc- 
tion of  the  shaft  with  the  curve,  perhaps  steadied  by  the  surgeon's 
finger.  The  immense  power  which  the  application  of  this  compound 
mechanical  principle,  in  the  construction  of  the  instrument,  gives  to 
it,  is  not  appreciated  by  surgeons.  The  ease  with  which  harm  may  be 
done,  in  using  force  with  conical  sounds,  is  rarely  realized  until  after 
an  accident  has  occurred,  and  then  the  surgeon  is  liable  to  ascribe  the 
mischief  to  chance  rather  than  to  his  own  carelessness.  Swelled  testi- 
cle, congestion  of  the  neck  of  the  bladder,  irritation  of  the  stricture^ 
even  false  passage,  may  be  produced  by  a  surgeon  in  too  great  a  hurry, 
or  using  force.  It  is  a  rule,  from  which  no  departure  should  be  made, 
either  on  account  of  solicitation  by  the  patient,  or  desire  to  push  the 
case  to  a  rapid  termination,  never  to  use  force  with  any  instrument  in 
the  urethra — especially  with  conical  steel  sounds.  The  character  of 
the  stricture  may,  occasionally,  in  the  judgment  of  the  operator,  some- 
times require  force,  but  the  motive  for  its  use  must  never  be  haste,  or 
desire  to  effect  a  rapid  cure.  The  weight  of  the  instrument,  aided  by 
a  little  coaxing,  will  usually  exert  all  the  power  necessary.  "  Festina 
lente "  is  the  golden  rule.  Patience  and  gentleness  will  effect  more 
than  force  in  the  long  run. 


118  STRICTURE  OF  THE  URETHRA. 


THOMPSON'S    RAPID    DILATOR. 

This  instrument  which  Thompson  devised  for  rapid  dihitation — his 
expressed  object  being  to  stretch  as  much  and  tear  as  little  as  possible 
— still  has  a  useful  place  among  the  instruments  for  the  treatment  of 
stricture.  Its  inventor  has  practically  discarded  it  in  favor  of  the  ure- 
throtome. In  this  country  it  is  still  used  as  a  dilator,  and  as  a  divul- 
sor  (to  stretch  a  strictured  point  so  as  to  tear  it)  in  appropriate  cases. 
The  American  instrument  is  modified  by  being  tunneled,  and  is  made 
stronger  and  to  open  more  widely  than  the  original  instrument  (Fig. 
40). 


Fig.  40. 


In  using  it,  the  slender  (size  12)  shaft  is  passed  so  that  its  point  of 
greatest  dilatability  is  placed  in  the  strictured  area.  This  is  easily 
accomplished  by  first  locating  the  stricture  with  a  bulbous  sound,  and 
then  introducing  the  divulsor  until  the  inch-marks  upon  the  shaft  in- 
dicate that  it  has  reached  the  proper  depth.  Now,  by  turning  the 
screw-head  in  the  handle,  the  blades  are  made  to  separate  laterally  to 
an  extent  indicated  by  markings  upon  the  slot  in  the  handle. 

When  it  is  used  upon  a  deep  stricture,  as  the  blades  are  being  again 
approached  after  the  divulsion  has  been  accomplished,  a  bit  of  mucous 
membrane  is  liable  to  be  caught  in  the  angle  of  the  blades,  near  the 
tip  of  the  instrument.  This  is  to  be  avoided  by  slowly  pressing  the 
tip  of  the  instrument  forward  into  the  bladder  as  the  blades  are  being 
approached. 

Divulsion,  or  tearing  the  stricture,  is  a  rough  manoeuvre,  and  has 
of  late  years  lost  favor  among  surgeons.  I  formerly  thought  better  of 
it  than  now,  and  at  the  present  date  very  rarely  have  recourse  to  it. 
Internal  urethrotomy  is,  undoubtedly,  a  better  operation  for  all  strict- 
ures situated  anteriorly  to  the  bulbo-membranous  junction,  but  deeper 
than  that  point,  although  I  still  believe  it  to  be  as  safe  as  extensive 
internal  urethrotomy,  yet  I  believe  it  not  to  be  as  safe  as  perineal  (ex- 
ternal) section. 

Yet  the  instrument  has  three  important  uses  : 

1.  To  pass  over  a  whalebone  guide  in  cases  of  very  tight  strictures, 
so  as  to  dilate  them  moderately  in  the  (a)  anterior  urethra,  in  order 
that  the  rather  large  shaft  of  the  dilating  urethrotome  may  be  made  to 


INSTRUMENTS  FOR   INTERNAL   URETUROTOMY.  119 

pass  ;  in  the  {h)  deep  urethra,  in  order  to  make  it  possible  to  take  np 
the  treatment  with  sounds  in  gradual  dilatation. 

2.  To  divulse  stricture  of  the  deep  urethra  in  the  occasional  cases 
where  that  operation  seems  to  be  called  for  when  the  patient  refuses 
external  section,  and  a  choice  lies  between  divulsion  and  deep  exten- 
sive internal  urethrotomy. 

3.  To  pick  up  and  remove  *  small  foreign  bodies  from  the  urethra. 

If  divulsion  be  practiced,  it  is  proper  to  perform  it  after  the  blad- 
der has  been  voluntarily  emptied,  or  to  pass  a  soft  rubber  catheter 
immediately  afterward,  and  tie  it  in  for  forty-eight  hours.  I  have 
gradually  come  to  the  belief  that  such  drainage  of  the  bladder  is  of 
assistance  in  averting  urethral  fever,  both  after  divulsion  and  after  deep 
internal  urethrotomy.  The  end  of  the  catheter  is  left  open  to  drain 
into  a  urinal,  and  the  patient  is  kept  in  bed  for  about  three  days. 
No  sound  needs  to  be  passed  until  the  seventh  day  after  divulsion, 
when,  if  the  operation  has  been  suflBciently  extensive,  a  full-sized  steel 
sound  will  enter.  After  this  the  cure  is  perfected  and  maintained 
with  the  steel  sound. 

No  after-dressing  is  required.  Ilgemorrhage  is  usually  very  mod- 
erate. 

Holt's,  Voillemier's,  and  other  divulsors  I  consider  less  accurate  in 
their  use,  and  less  suitable  for  divulsion,  than  Thompson's  dilator. 

INSTRUMENTS    FOR    INTERNAL    URETHROTOMY. 

Four  cutting  instruments  only  need  be  described  suitable  for  di- 
viding strictures  in  different  portions  of  the  urethra. 

The  straight  bistoury  is  the  best  instrument  for  dividing  strictures 
at  and  quite  near  the  external  meatus.  These  should  always  be  cut 
uj)on  the  floor  of  the  urethra  to  an  extent  suflScient  to  cut  through  all 
the  morbid  fibrous  thickening  which  constitutes  the  stricture. 

The  finger  is  placed  beneath  the  urethra,  and,  with  the  bistoury, 
the  stricture  is  to  be  slowly  and  thoroughly  cut  through  until  the  fin- 
ger on  the  outside  recognizes  that  nothing  of  the  former  hardened  ring 
is  left  between  the  edge  of  the  knife  and  the  integument.  Bleeding, 
generally  moderate,  is  sometimes  profuse.  The  best  method  of  arrest- 
ing it  is  to  pinch  together  the  cut  edges,  arresting  the  flow  tempo- 
rarily. Then  wij^e  off  the  glans  penis  until  it  becomes  perfectly  dry. 
Then  wrap  it  around  many  times  with  a  strip  of  rubber  plaster  one 
quarter  of  an  inch  wide  and  ten  inches  long,  wrapping  in  all  the  head 
of  the  penis  in  a  circular  manner.  This  will  always  and  without  fail 
permanently  arrest  haemorrhage.  The  pendulous  urethra  fills  up  with 
blood  which  can  not  escape,  and  clots  filling  the  canal.  At  each  act 
of  urination  this  dressing  must  be  removed,  and  immediately  after 

*  Keyes,  "New  York  Medical  Record,"  March  6,  1875. 


120  STRICTURE  OF  THE  URETHRA. 

urination  reapplied.     This  the  patient  can  do  perfectly  well  for  him- 
self. 

The  meatus  tends  to  heal  promptly.  My  custom  is  to  ]iass  a  full- 
sized  steel  sound  through  the  cut  at  24:,  48,  72,  and  90  hours'  interval, 
respectively,  after  which  the  cut  is  nearly  well,  and  a  sound  twice  a 
week  will  perfect  the  cure  in  a  week  or  ten  days. 


CrVI ALE'S    URETHROTOME. 

This  instrument  has  a  small  straight  shaft  terminated  by  a  flat- 
tened bulb  wliich  conceals  a  rounded  blade  (Fig.  41).  By  means  of  a 
mechanism  in  the  handle,  this  blade  may  be  protruded  to  an  extent 
indicated  upon  a  register  in  the  handle.     The  bulb  is  to  be  passed 

Fig.  41. 

throuofh  a  given  stricture,  withdrawn  until  it  encounters  the  stricture, 
when  the  blade  is  to  be  protruded,  and  the  stricture  is  cut  by  with- 
drawing the  instrument.  It  is  a  very  safe  urethrotome.  Thompson 
uses  it  (slightly  modified)  almost  exclusively.  It  is  most  serviceable 
in  cases  of  single  linear  well-defined  stricture  of  the  pendulous  urethra. 
Several  modifications  of  this  instrument  have  been  devised — bulbs 
of  varying  sizes  being  screwed  upon  the  same  shaft.  Hsemorrhage  is 
arrested,  as  after  meatotomy,  by  wrapping  a  long  strip  of  rubber  pla.s- 
ter  about  the  glans  penis.  After-treatment  is  the  steel  sound  of  full 
size  passed,  as  in  the  case  of  meatotomy.  The  sound  should  not  enter 
the  bladder  when  the  stricture  which  has  been  cut  is  situated  in  the 
pendulous  urethra.  This  rule  applies  to  the  after-treatment  in  all  the 
varieties  of  cutting  in  the  pendulous  urethra. 

MAISONNEUVE'3    URETHROTOME. 

This  instrument  is  serviceable  where  it  becomes  necessary  to  incise 
stricture  situated  deeper  in  the  urethra  than  four  inches.  It  consists 
of  a  hollow  wire  with  a  linear  opening  on  that  side  which  coiTesponds 
to  the  roof  of  the  urethra.  The  knife,  of  different  sizes,  cutting  from 
before  backward,  and  from  behind  forward,  with  its  exposed  obtu.se 
angle  always  blunted,  is  attached  to  the  end  of  a  long  stylet  which  fits 
into  the  groove  of  the  instrument.  The  blade  is  prevented  from  slip- 
ping out  by  a  projecting  shoulder  on  either  side,  which  runs  inside 
the  hollow  wire.  Bumstead  has  advantageously  modified  the  original 
instrument  by  making  the  knife  run  only  to  the  beginning  of  the 
curve,  instead  of  up  to  the  point,  and  by  making  the  tube  a  little 
more  solid.     Bumstead's  instrument  has  the  blade  on  the  lower  side 


INSTRUMENTS  FOR   INTERNAL   URETHROTOMY. 


121 


(Fig.  42).  This  urethrotome  is  to  be  used  with  a  scrcw-tii)pod  fili- 
form bougie.  It  is  proper  to  cut  the  meatus  below,  the  pendulous 
urethra  above,  the  curved  urethra  below. 

It  is  introduced,  following  its  guide,  and 
depressed  until  the  straight  portion  of  the 
tube  has  passed  the  stricture.  Then  the 
blade  is  entered,  pushed  rapidly  down,  as  far 
as  it  will  go,  and  immediately  retracted. 

The  objection  to  this  instrument  is,  that 
if  a  large  blade  is  used  the  healthy  urethra 
is  incised  longitudinally,  often  for  its  whole 
length  anteriorly  to  the  stricture ;  an  acci- 
dent perhaps  of  no  very  great  moment,  but 
entirely  unnecessary,  while,  if  a  small  blade  is 
used,  the  whole  thick- 
ness of  the  stricture 
is  not  cut  through. 
Voillemier  has  at- 
tempted to  overcome 
this  objection  by 
adapting  a  shield  to 
the  blade  from  which 
the  latter  may  be 
protruded  when  the 
stricture  has  been 
reached,  but  the 
modification  is  com- 
plicated and  unsat- 
isfactory (Fig.  43). 
Another  objection, 
applicable  to  all  in- 
struments for  incising 
the  deep  urethra,  is 
the  liability  to  haemor- 
rhage if  the  incision 
is  sufficiently  deep  to 
be  effective.  Such 
hasmorrhage  at  the 
bulbous     portion     of 

the  canal  may  be  very  difiScult  to  control, 
the  same  as  after  all  other  operations. 

The  best  way  to  control  hemorrhage  in  the  deep  urethra  after 
deep  internal  urethrotomy  is  by  a  padded  perineal  crutch,  the  leg  of 
the  crutch  resting  against  the  foot-board,  counter-pressure  being  ef- 
fected by  elevating  the  head  of  the  bed. 


Fig.  43. 


The  after-treatment  is 


122 


STRICTURE   OF   THE   URETHRA. 


OTIS'S   DILATING   URETHROTOME. 

Tliis  powerful  instrument  (Fig.  44)  is  a  very 
valuable  one  for  cutting  strictures  in  the  pendulous 
urethra.  It  has  a  straight,  oval  shaft,  about  size  20 
(a  smaller  instrument  aud  a  corresi)ondiugly  lighter 
one  is  made,  but  the  stiffer  one  is  the  better).  The 
end  of  the  shaft  is  tunneled  for  use  in  the  deeper 
urethra,  if  necessary  upon  a  whalebone  guide.  The 
two  segments  of  the  shaft  are  separated  b}'  turning 
the  screw  in  the  handle,  the  extent  of  se]iaration 
being  registered  upon  a  plate  upon  the  handle. 
The  possible  extent  of  this  separation  is  forty-five. 
The  knife  is  narrow,  concealed  in  the  shaft  at  a 
point  near  the  end  of  the  instrument.  It  is  dis- 
closed by  withdrawal,  when  it  rides  upon  a  ridge 
which  is  continuous  up  to  the  handle.  The  instru- 
ment is  introduced  until  the  point  of  emergence  of 
the  knife  is  about  half  an  inch  behind  the  deepest 
stricture  to  be  cut.  The  blades  are  then  separated 
until  the  stricture  is  well  upon  the  stretch.  The 
knife  is  withdrawn,  cutting  the  tense  tissues.  The 
instrument  may  be  then  still  further  screwed  up  if 
desired,  and  the  cutting  continued  to  any  extent — 
upon  the  roof  of  the  urethra.  The  whole  roof  or  a 
l^ortion  of  it  may  be  cut.  The  knife  is  then  re- 
turned, the  instrument  unscrewed  and  withdrawn. 
Cocaine  makes  the  operation  comparatively  painless. 
A  full-sized  sound  is  then  introduced  to  prove  that 
the  cutting  has  been  effectual.  Ila^morrhage  is 
arrested  as  in  meatotomy,  and  the  after-treatment 
is  as  before  with  sounds. 

Wyeth's  urethrotome,  a  similar  and  cheaper  in- 
strument, serves  very  well  as  a  substitute.  It  is  not  as  strong  an  in- 
strument as  that  of  Professor  Otis. 


Fig. 


INSTRUMENTS   FOR   EXTERNAL    PERINEAL    URETHROTOMY. 

Besides  some  of  the  special  instruments  already  described,  only  two 
others  are  requisite  to  meet  the  requirements  of  external  section. 

1.  A  simple  staff,  broadly  grooved  on  its  convexity,  the  groove 
running  off  at  the  end,  and  the  instrument  not  conical  (Fig.  45). 
This  instrument  is  introduced  as  far  as  the  stricture,  when  the  latter 
is  impervious,  and  is  cut  upon  in  the  operation  of  perineal  urethrot- 
omy without  a  guide.  It  may  be  used  with  a  guide,  the  latter  being 
a  whalebone  bougie,  introduced  through  the  stricture  (Fig.  40).     In 


EXTERNAL  URETHROTOMY  WITHOUT  A  GUIDE. 


123 


this  case  it  is  practically  the  same  instrument  as  the  stafE  of  Syme,* 
the  eminent  surgeon  who  gave  this  operation  its  reputation.  Syme's 
staff  is  unsafe  compared  with  the  means  now  at  our  command,  and  is 
rarely  iised. 

2.  The  catheter-staff  of    Gouley  (Fig.  47).     This  most  excellent 
instrument  is  a  metallic  catheter  (they  are  made  of  various  sizes), 


Fig.  45. 


Fig.  43. 


Fig.  47. 


grooved  on  its  convexity,  the  groove  being  bridged  over  at  its  end, 
forming  a  loop  to  receive  its  guide — a  filiform  whalebone  bougie. 

Scalpels,  probes,  and  a  long,  slender,  probe-pointed  director  are 
required  for  the  operation. 


EXTERNAL   PERINEAIi   URETHROTOMY,   WITEOTJT   A   GUIDE. 

The  surgeon  who  proposes  to  perform  this  operation  should  be 
thoroughly  at  home  in  the  anatomy  of  the  perinaeum,  and  even  then 
should  be  prepared  for  possible  failure.  The  patient  is  tied  or  held  in 
the  lithotomy  position,  after  he  has  been  anesthetized.  The  scrotum 
is  held  up  out  of  the  way  by  the  assistant  who  manages  the  grooved 
staff.     Ether  relaxes  spasm,  and  a  last  attempt  to  pass  a  filiform 

*  "  Stricture  of  the  Urethra,"  Edinburgh,  18-19. 


124  STRICTURE   OF   THE   URETHRA. 

bougie,  after  the  patient  has  become  uncouscious,  may  be  successful, 
where  previous  efforts  have  failed.  Should  the  attempt  succeed,  the 
operation  at  once  becomes  simi)lo  and  easy.  Failing,  the  operation 
without  a  guide  must  be  undertaken.  The  perint^um  having  been 
shaved,  an  external  incision  should  be  made  directly  in  the  median  line, 
from  two  and  a  half  to  three  inches  long.  It  should  be  carried  down, 
layer  after  layer,  until  the  urethra  has  been  ojjcned  into  upon  the  end 
of  the  blunt  staff  previously  introduced  up  to  the  front  face  of  the 
stricture.  The  perinfeum  should  be  turned  toward  a  window,  and  a 
couple  of  hours  of  daylight  always  allowed,  in  order  to  have  an  abund- 
ance of  time,  if  the  operation  proves  complicated.  Haste,  in  this 
operation,  is  bad  surgery.  After  the  urethra  has  been  laid  open,  the 
subsequent  steps  of  the  operation  are  greatly  simplified  by  adopting 
Avery's  suggestion  for  getting  room  and  light.  It  consists  in  trans- 
fixing each  flap  of  the  wound  with  a  stout  ligature  about  three  feet 
long.  The  ends  of  each  ligature  are  now  knotted,  thus  forming  a  long 
loop  on  either  side,  which  may  be  held  by  assistants.  By  means  of 
these  loops  the  wound  is  kept  open  to  the  bottom  without  the  neces- 
sity of  thrusting  fingers  or  spatulas  into  the  small  s^^ace,  where  the 
fingers  of  the  operator  alone  are  necessary. 

With  the  urethra  opened  in  front  of  the  stricture,  the  surgeon  care- 
fully searches  for  the  anterior  opening  of  the  latter  with  a  fine  probe, 
or,  better,  a  fine  probe-pointed  director.  If  the  opening  can  be  found, 
and  the  director  passed  through  it,  the  rest  of  the  operation  is  simpli- 
fied at  once  ;  but  this  fortunate  result  is  rare.  Having  failed  to  find 
the  orifice  of  the  stricture,  after  a  patient  search,  the  surgeon  feels  for 
the  hole  m  the  triangular  ligament,  below  the  depression  lying  above 
the  sub-pubic  ligament,  and  cuts  into  it  through  the  fibrous  mass  by 
successive  strokes  of  the  scalpel,  always  in  the  median  line.  At  short 
intervals  during  the  operation,  the  surgeon  gently  endeavors  to  coax 
his  fine  director,  properly  curved,  through  any  opening  he  may  think 
he  sees,  into  the  dilated  urethra  beyond.  After  each  failure  he  re- 
sumes the  cutting  in  the  median  line,  guiding  his  knife  by  frequently 
taking  the  bearings  of  the  tubera  ischii,  and  with  his  finger  in  the 
rectum.  In  this  way  he  continues,  feeling  his  way  as  he  goes,  until 
finally  his  director  finds  some  orifice  through  which  it  passes  onward 
into  the  bladder.  When  this  has  been  effected,  a  probe  is  passed  in  the 
groove  of  the  director,  also  into  the  bladder  ;  and  now,  by  separating 
the  two,  a  gush  of  urine  is  seen  to  mingle  with  the  blood,  announc- 
ing that  the  bladder  has  been  reached. 

The  director,  once  in  the  bladder,  should  not  be  removed  until 
after  the  opening  has  been  increased,  and  a  large  instrument  (nothing 
is  better  than  the  little  finger)  can  pass  into  the  bladder.  A  mistake 
often  made  in  searching  for  the  opening  into  the  urethra  with  a  probe 
is  in  trying  too  high  up,  too  near  the  sub-pubic  ligament. 


EXTERNAL  URETHROTOMY  WITHOUT  A  GUIDE.        125 

Having  now  opened  a  way  into  the  bladder,  all  fibrous  bunds  in 
the  roof  of  the  urethra'*  must  be  cut  with  the  knife,  and  any  fibrous 
material  detected  in  the  floor  of  the  canal,  at  either  extremity  of  the 
incision,  should  be  freely  divided.  Finally,  a  blunt  steel  sound,  as 
large  as  the  urethra  will  admit,  should  be  passed  through  the  meatus 
into  the  bladder,  the  meatus  being  cut  if  necessary.  This  sound 
should  be  introduced  several  times,  to  make  certain  that  it  glides 
easily  and  without  obstruction.  If  the  stricture  is  an  old  one,  it  is 
always  well  to  search  the  bladder  for  stone  after  the  operation,  and  to 
remove  any  that  may  be  found.  Venous  haemorrhage  may  be  abund- 
ant, but  it  is  easily  restrained  by  plugging  the  wound  with  lint  or  tow, 
and  tying  the  legs  together  after  the  operation.  The  scrotum  should 
be  bandaged  up  out  of  the  way,  to  prevent  the  possible  infiltration  of 
its  loose  tissue  by  blood  or  urine.  The  thighs  should  be  elevated,  and 
a  cradle  used  to  keep  off  the  weight  of  the  bed-clothes. 

This  operation  may  be  greatly  simplified  by  puncturing  the  dilated 
urethra  in  the  median  line,  if  it  should  be  found  to  be  distended  with 
urine  behind  the  stricture,  as  is  sometimes  the  case.  Through  such  an 
opening,  an  instrument  may  be  passed  to  the  posterior  face  of  the  ob- 
struction, and  thus  serve  to  guide  the  incisions  from  the  grooved  staff 
at  the  front  face  of  the  stricture  through  the  callous  mass.  A  perineal 
fistula  may  be  utilized  for  the  same  purpose. 

After  the  operation,  a  large,  soft,  red  rubber  catheter,  size  30  or 
35,  should  be  introduced  into  the  bladder  through  the  perineal  wound, 
and  tied  in  by  encircling  it  close  to  the  wound  with  two  long,  narrow 
strips  of  soft  bandage,  which  in  their  turn  are  tied  to  a  waist-bandage, 
one  of  the  narrow  bandages  running  up  on  either  side  of  the  scrotum, 
the  other  ends  of  the  narrow  bandages  being  passed  under  the  thigh 
on  either  side,  brought  around,  and  attached  to  the  waist-band  in  the 
flank.  The  end  of  the  tube  is  left  open,  deposited  in  a  urinal  between 
the  patient's  thighs.  Such  a  tube  drains  the  bladder  and  keeps  it 
empty.  It  is  usually  well  borne  for  two  or  three  days,  after  which 
it  has  served  its  purpose  and  may  be  removed.  Through  it  the  blad- 
der can  be  washed  with  an  appropriate  solution  in  case  of  cystitis,  or 
retained  decomposing  blood,  or  when  the  urine  is  putrid.  Around 
the  tube  a  piece  of  cotton  cloth  may  be  tied  as  in  the  shirted  cannula, 
and  this  may  be  stuffed  with  a  long  piece  of  narrow  bandage,  making 
the  most  effectual  pressure  in  case  of  haemorrhage.  The  tube  in  my 
experience  almost  totally  does  away  with  the  urinary  fever.  The  tes- 
timony of  Berkeley  Hill,  f  who  cites  the  twenty  cases  of  Davies,  and 
of  Reginald  Harrison  J  is  corroborative  of  the  good  effects  of  a  tube 

*  A  neglect  of  this  precaution  sometimes  renders  the  subsequent  introduction  of  in- 
struments very  difficult. 

f  "British  Medical  Journal,"  ISYQ,  p.  SS4. 

X  Reprint  from  "  British  Medical  Journal,"  July  18,  1SS5. 


126  STRICTURE   OF   THE   URETHRA. 

tied  in  for  this  purpose.  Tiie  tube  should  be  removed  on  the  third  to 
the  fifth  day.  After  it  is  removed,  the  urine  at  first  passes  through 
the  perineal  oi)ening. 

The  aft-er-treatment  consists  in  the  passage  of  a  full-sized  steel 
conical  instrument  into  the  bladder,  commencing  on  the  fourth  day 
and  repeating  every  three  or  four  days  until  the  wound  has  healed, 
thus  forcing  it,  as  it  were,  to  heal  with  a  large  splice.  After  the 
wound  has  united,  to  prevent  recontraction,  the  patient  must  pass  di- 
lating instruments  at  proper  intervals,  as  after  any  other  treatment 
designed  to  effect  a  radical  cure  of  organic  stricture.  Infiltration  and 
abscess  may  occur  after  the  operation,  and  it  is  not  very  uncommon 
for  fever  to  run  high  ;  but  the  results  are  usually  excellent,  unless  the 
patient  have  organic  kidney  or  other  disease.  Diluent,  mucilaginous, 
alkaline  cooling  drinks,  with  quinine,  tonics,  supporting  diet,  and 
rest,  complete  the  treatment. 


EXTERNAL  PERINEAL  URETHROTOMY,  WITH  A  GUIDE. 

This  is  an  operation  much  simpler  than  the  one  just  described. 
When  external  section  of  a  stricture  is  contemplated,  no  effort  should 
be  spared  and  no  amount  of  time  grudged  which  is  given  to  attempts 
at  introducing  a  whalebone  bougie.  Even  after  the  patient  has  been 
anaesthetized,  the  attempts  should  be  renewed,  for  ether  always  relaxes 
urethral  spasm,  and,  if  finally  a  whalebone  guide  enters  the  bladder, 
the  surgeon  may  congratulate  himself  and  the  patient's  friends — for 
what  would  have  been  one  of  the  more  difficult  operations  of  surgery 
(section  without  a  guide)  becomes  at  once  one  of  the  easiest. 

A  whalebone  once  in  the  bladder,  the  catheter-staff,  or  a  tunneled 
steel  staff,  is  passed  over  it  up  to  the  stricture.  An  incision  through 
the  perinaeum  in  the  median  line  readily  exposes  the  end  of  the  staff, 
and  be5'ond  it  the  black  guide  is  seen  disapiaearing  among  the  tissues. 
Avery's  threads  make  it  easy  to  keep  the  guide  in  view,  and  a  little 
careful  following  up  of  this  conductor  soon  lets  the  surgeon  into  the 
dilated  urethra  behind  the  stricture  ;  the  catheter-staff  passes  on  into 
the  bladder,  urine  flows  through  it,  and  the  operation  is  satisfactorily 
accomplished.  The  only  precaution  worth  mentioning  is  the  neces- 
sary exercise  of  care  not  to  cut  off  the  whalebone  guide  in  front  of  the 
staff  by  a  careless  stroke  of  the  knife,  as  this  might  at  once  reduce  the 
surgeon  to  the  necessity  of  operating  without  a  guide.  After-treatment 
is  the  same  as  after  the  operation  without  a  guide. 

Harrison's  operation  of  combined  external  and  internal  urethroto- 
my is  a  modification  devised  to  meet  the  well-known  dangers  attend- 
ant upon  deep  internal  urethrotomy.  It  consists  simply  in  cutting 
the  strictures  internally  in  any  manner  to  the  extent  desired,  and  then 
passing  a  broadly-grooved  staff  and  puncturing  the  perinaeum  from 


THE   ASPIRATOR.  127 

the  outside  sufficiently  to  allow  the  insertion  of  a  large  tuhe  into  the 
bladder  for  the  purpose  of  drainage — and,  most  particularly,  to  avert 
urinary  fever  of  bad  type.  His  showing  is  an  excellent  one,  and  com- 
mends itself  to  common  sense.  The  simple  puncture  of  the  perinaeum 
does  not  add  to  the  gravity  of  the  internal  operation,  and  experience 
is  daily  accumulating  to  show  that  this  thorough  bladder  drainage  is 
a  potent  factor  for  good  in  operations  upon  the  bladder.  At  the  pres- 
ent date  I  invariably  use  it  in  all  cases  of  supra-pubic  section,  and  I 
can  not  commend  it  too  highly.  My  personal  experience  with  deep 
internal  urethrotomy  is  unsatisfactory,  and  I  do  not  care  to  employ  it 
in  any  grave  case  except  in  combination  with  thorough  bladder  drain- 
age through  a  tube  in  the  perinseum.  The  profession  is  indebted  to 
Harrison  for  the  admirable  manner  in  which  he  has  called  attention 
to  this  fact.* 

Certain  other  operations  on  stricture  must  be  mentioned  to  be  con- 
demned. Cutting  out  strictures  is  absurd,  for  the  circular  wound 
leaves  traumatic  stricture  behind.  Dupuytren's  vital  dilatation,  which 
consists  in  tying  in  a  large  instrument  pressed  against  the  front  of  the 
stricture  in  the  hope  that  it  may  pass  after  many  hours,  is  unsurgical, 
and  has  been  superseded  by  better  methods.  Wakley's  sliding  tubes 
are  clumsy,  and  Arnold's  fluid  pressure  less  good  than  any  other  press- 
ure. Time  has  judged  the  internal  use  of  caustics  and  condemned 
them,  while  the  same  fate  awaits  electrolysis,  lately  revived.  My  ex- 
perience with  it  has  been  unfortunate,  f 

Puncture  of  the  Bladder  above  the  Pubis.  —  Puncture  of 
the  bladder  through  the  rectum,  formerly  much  resorted  to,  has  been 
replaced  by  better  methods.  J 

THE    ASPIRATOR. 

This  most  useful  instrument,  devised  by  Dieulafoy,  of  Paris,  exists 
at  the  present  day  in  the  shops  in  various  forms.  Its  value  in  cases  of 
retention,  from  whatever  cause,  can  hardly  be  overestimated.  It  may 
be  used  day  after  day,  and  several  times  a  day  if  necessary,  the  fine 
needle  (I  prefer  No.  2)  being  inserted  with  as  much  impunity  into  the 
bladder  above  the  pubis  as  is  customary  in  using  a  hypodermic  needle 
for  the  purpose  of  subcutaneous  injection.  The  little  wound  closes 
without  bleeding  after  the  needle  is  withdrawn,  and  subsequent  punc- 
tures may  be  made  quite  near  to  the  original  one  without  provoking 

*  "British  Medical  Journal,"  July  18,  1885. 

f  "  Practical  Electrotherapeutics,  Ten  Cases  of  Organic  Stricture  treated  by  Electroly- 
sis," Keyes,  "New  York  Medical  Journal,"  December,  1871,  p.  569. 

X  As  to  tbe  comparative  danger  to  life  in  supra-pubic  and  rectal  puncture,  Deneife  and 
Van  Wetter,  "Rev.  Mens,  de  Med.  et  de  Chir.,"  September,  1877,  have  collected  97  cases 
of  rectal  puncture  with  11  deaths,  and  152  supra-pubic  with  6  deaths.  They  only  cite,  at 
that  date,  57  cases  of  aspiration — no  accident. 


12S 


STRICTURE   OF  THE   URETHRA. 


any  local  inOammation.  Generally,  aspiration  is  only  ])racticed  as  a 
temporizing  expedient  in  cases  of  stricture  when  it  is  not  desirable  for 
some  reason  to  operate  at  once.  In  this  way  the  bladder  may  often  be 
spared  needless  overdistention.  Furthermore,  quite  often  when,  in  a 
case  of  retention  with  tight  stricture,  no  filiform  instrument  can  be 
made  to  pass,  if  aspiration  is  practiced,  another  attempt,  made  some 
hours  later,  is  successful. 

One  precaution  is  necessary  in  using  the  aspirator,  namely,  main- 
tain the  suction  while  the  needle  is  being  withdrawn.  W.  T.  Bull* 
calls  attention  to  this  point  in  the  only  case  of  which  I  am  aware  in 
which  a  bad  result  followed  the  use  of  the  aspirator.  In  this  case  an 
abscess  with  cellulitis  in  front  of  the  bladder  followed  a  second  aspira- 
tion in  a  given  case.     The  patient  recovered  after  several  weeks. 

Dieulafoy's  smaller  aspirator  is  very  ^■)ortable  and  convenient  for 
tapping  the  bladder  ;  the  box  containing  it  measures  eight  and  a  half, 

by  four  and  a  half,  by  one  and  three-eighths 
inches.  It  consists,  essentially,  of  a  glass 
cylinder,  with  tight-fitting  piston  and  two 
stop-cocks,  a  flexible  tube,  and  pointed  hol- 
low needle. 

The  method  of  using  the  instrument  is 
the  following  :  First,  be  satisfied  that  the 
fine  needle  is  pervious — not  occluded  by  rust 
or  otherwise.  Attach  it  beyond  stop-cock 
E,  or  to  the  flexible  tube,  as  shown  in  the 
figure.  Shut  both  stop-cocks,  E  and  E' ; 
withdraw  the  piston  forcibly,  thus  forming 
a  vacuum.  By  a  half-turn  from  left  to  right, 
hook  the  angle  A  above  the  point  B,  thus 
keeping  the  piston  withdrawn.  The  instru- 
ment is  now  ready  for  use. 

The  point  of  election  in  puncture  of  a 
distended  bladder  is  through  the  linea  alba, 
about  half  an  inch  above  the  symphysis 
pubis.  Into  this  spot  the  needle  is  plunged 
for  half  an  inch.  Now  stop-cock  E  is  turned 
Fio.  48.  on,  and  a  vacuum  is  thus  created  within  the 

flexible  tube  and  needle.  Next,  the  needle 
is  slowly  and  cautiously  pushed  forward  until  urine  is  seen  to  flow 
into  the  glass  cylinder.  It  flows  slowly  on  account  of  the  size  of  the 
needle,  but  no  pressure  is  required  to  help  it.  The  ueedle  is  next 
jiushed,  perhaps,  an  inch  farther  into  the  bladder,  and  then  there  is 
nothing  more  to  do  until  the  glass  cylinder  is  full,  after  which  E  is 
turned  off,  E'  is  turned  on,  A  is  unhooked,  the  piston  is  driven  gently 

*  "  New  York  Medical  Journal,"  September,  18S0,  p.  305. 


THE   ASPIRATOR.  129 

home,  expelling  the  iirinc  at  R'.  E'  is  now  turned  off,  the  cylinder 
again  exhausted,  li  turned  on,  and  so  on,  until  the  bladder  is  relieved, 
after  which,  the  vacuum  of  the  cylinder  being  maintained,  the  needle 
is  rapidly  withdrawn.  The  operation  may  be  repeated  as  soon  as  the 
bladder  refills. 

The  impunity  with  which  the  bladder  may  be  tapped,  even  with  a 
large  instrument,  may  perhaps  be  best  illustrated  by  a  case  reported 
by  Dr.  Clarke,*  of  Geneva,  New  York.  The  case  was  one  of  reten- 
tion, from  enlarged  prostate,  where  catheterism  proved  impossible. 
Dr.  Dox  punctured  the  bladder  above  the  pubes,  without  any  previous 
incision  of  the  skin,  with  an  ordinary  trocar,  one  line  in  diameter, 
and  evacuated  two  quarts  of  urine,  after  which  the  cannula  was  imme- 
diately withdrawn.  This  operation  was  repeated  six  times  in  eight 
days,  without  any  precautions,  and  was  followed  by  no  ill  effects. 
After  the  eighth  day  the  patient  reacquired  (and  at  the  date  of  the  arti- 
cle still  retained)  the  power  of  urinating  by  the  urethra,  as  well  as  he 
had  before  his  retention.  Such  an  excellent  result  could  not  be 
counted  on  in  most  cases,  f  One  case  is  recorded  J  in  which  the  blad- 
der of  an  old  man  of  ninety  was  aspirated  once  a  day  for  five  weeks. 
No  cystitis  occurred — only  a  little  cutaneous  inflammation  at  the  point 
of  punctures. 

Sometimes  suprapubic  puncture  has  to  be  practiced  for  the  pur- 
pose of  establishing  a  permanent  outlet  for  the  urine  in  cases  where 
it  is  inexpedient  or  impracticable  to  re-establish  the  natural  right  of 
way.  In  such  cases  the  aspirator  is  not  suitable,  for  a  permanent 
tube  must  be  placed  to  be  worn  by  the  patient  as  long  as  required. 
A  red  rubber  catheter  serves  admirably  in  ordinary  cases,  while  the 
wound  is  healing.  Its  place  is  supplied  finally,  for  permanent  use, 
by  some  suitable  tube. 
I  have  recently  had  such 
a  tube  constructed  (Fig. 
49),  and  found  that  it 
worked  satisfactorily. 
The  tube  is  of  red  soft 

rubber,     the     spool     is  Fig.  49. 

made    of     black    hard 

rubber,  and  the  outside  continuation  tube  also  of  hard  rubber.  Upon 
this  latter  another  soft  tube  is  fastened,  conducting  into  a  urinal. 
The  hard-rubber  spool  facilitates  attachment  by  bandage.  A  long 
silver  double  tube,  like  a  tracheotomy  tube,  may  also  be  employed 
(Fig.  50). 

*  "  Medical  Record,"  June  1,  18'72. 

f  Maisonneuve  was  in  the  habit  of  puncturing  bladders  in  this  manner,  ^Ith  an  ordi- 
nary fine  trocar,  at  the  Hotel-Dieu,  Paris,  in  1866. 
I  Hague,  "Lancet,"  August  20,  1885,  p.  385. 
9 


130  STRICTURE  OF  THE  URETHRA. 

The  tube  last  pictured  was  devised  by  Dr.  Van  Buren  and  intro- 
duced into  uu  old  gentleman  with  obstructive  prostatic  disease — an 


Fio.  50. 


obstruction  that  no  catheter  could  be  made  to  pass — in  the  year  1863. 
The  patient  wore  it  comfortably  for  many  months. 

The  operation  is  not  a  difficult  one.  The  mons  veneris  is  shaved, 
and  an  incision  made  down  to  and  through  the  linea  alba.  Then 
the  bladder  is  exposed  as  in  the  high  operation  for  stone,  and  through 
a  puncture  a  large  red  rubber  catheter  (30  F.)  is  inserted.  When  the 
wound  has  healed  around  the  catheter,  the  tube  to  be  permanently 
worn  is  introduced. 

Puncture  through  the  symphysis  pubis,  and  below  the  pubcs  along- 
side of  the  root  of  the  penis,  has  not  yielded  satisfactory  results. 

Puncture  through  the  perina^um  and  through  the  substance  of  the 
prostate  has  been  advocated  by  Harrison.*  Ho  leaves  the  silver  tube 
in,  and  affirms  that  this  })unctnre  with  retained  tube  caused  the  en- 
larged i^rostate  to  atroiDhy. 


CHAPTEK  YII. 

STRICTURE  OF  THE    URETHRA. 

Diagnosis.— Use  of  Enlbous  Bougie.— Sj-mptoms  of  Stricture  and  its  Results  as  affecting  the  Ure- 
thra, Bladder,  Kidneys,  Testicles,  Rectum,  Nerves,  etc.,  including  a  Consideration  of  Infiltra- 
tion, and  the  Hanulessness  of  Healthy  Urine  in  Contact  with  the  Tissues.— Causes  of  Death 
from  Stricture.— Recapitulation  of  Symptoms  and  Effects  of  Stricture. 

Diagnosis. — Few  morbid  conditions  of  the  body  are  more  easy  of 
diagnosis  than  organic  stricture  of  the  urethra.  In  exploring  a  given 
urethra  for  the  first  time  for  stricture,  I  prefer  to  use  a  blunt  steel  sound 
which  will  just  pass  the  meatus — that  is,  when  the  latter  itself  is  not 
abnormally  small.  The  blunt  sound  causes  less  pain  than  either  the 
bulbous  bougie  or  the  urethrameter.  It  should  be  warmed,  lubricated, 
and  introduced  with  all  gentleness.  If  it  is  obstructed  anywhere, 
there  is  stricture,  for  the  meatus  is  normally  the  smallest  part  of  the 
canal.  When  an  obstruction  is  encountered,  a  smaller  blunt  sound  is 
selected,  and  then  another,  until  some  sound  will  enter  the  bladder. 

*  "  British  Medical  Journal,"  December  24,  1881,  and  April  8,  1882. 


DIAGNOSIS.  ],31 

It  is  always  well  in  searching  for  stricture  to  commence  wii.h  a  hu-'^o. 
size  and  work  down,  rather  tlian  to  begin  with  a  small  instrument. 
The  other  method  leads  to  confusion.  I  have  more  than  once  in  hos- 
pital and  in  my  office  had  a  case  referred  to  me  as  one  in  which  a  fili- 
form instrument  even  can  not  be  made  to  enter  the  bladder,  and  have 
at  once  passed  a  full-sized  blunt  steel  sound  easily  into  the  bladder. 
The  explanation  of  this  is  that  spasm  of  the  deep  urethra  frequently 
fails  to  allow  a  fine  instrument,  especially  a  pointed  one,  to  pass, 
while  spasm  in  that  region,  in  my  experience  at  least,  always  yields  to 
gentle  pressui'e  slowly  and  accurately  applied  with  a  blunt  steel  sound. 
Moreover,  a  false  passage,  or  a  pouched  sinus  of  the  bulb,  or  a  dilated 
follicle,  will  frequently  catch  the  point  of  a  fine  instrument,  while  a 
blunt  sound  will  escape  the  obstacle,  and,  presenting  fairly  at  the 
bulbo-membranous  junction,  will  presently  pass,  perhaps  smoothly, 
perhaps  with  a  little  jump  as  it  rides  out  of  the  sinus  of  the  bulb  into 
the  membranous  urethra. 

Having  detected  stricture,  it  may  be  located,  calibrated,  and  meas- 
ured, either  with  a  metallic  bulbous  bougie  or  the  urethrameter  in  the 
anterior  urethra,  or  with  a  flexible  bulbous  bougie  in  the  deep  urethra. 
Obstructions  beyond  six  and  a  half  inches  may  generally  be  set  down 
as  due  to  prostatic  enlargement,  particularly  in  patients  older  than 
fifty  years.  If  the  bulbous  bougie  or  urethrameter  be  used  alone, 
there  is  danger  of  assuming  that  the  point  of  physiological  narrowing, 
at  about  the  middle  of  the  pendulous  urethra,  is  a  stricture  requir- 
ing treatment  by  cutting  when  there  is  no  real  occasion  for  the 
operation.  If  this  point  is  covered  by  granulations,  however,  and 
bleeds  as  the  bulb  passes  it,  it  is  in  a  morbid  condition,  and  may  re- 
quire cutting,  although  no  true  stricture  exists  at  the  point — only  the 
natural  narrowing  rendered  granular  upon  its  surface  by  the  pro- 
longed existence  of  chronic  inflammation  at  this  point.  These  are 
the  so-called  strictures  of  large  caliber  so  popular  at  the  present  day, 
so  common  in  occurrence,  a  rich  field  for  the  young  surgeon,  and 
sometimes  the  occasion  of  unnecessary  cutting,  as  it  appears  to  me. 
for  the  gleet  they  occasion  may  often  be  removed  permanently  by  a 
few  passages  of  a  large  sound  without  having  recourse  to  the  knife, 
and  in  most  instances,  when  the  gleet  has  been  cured  by  the  sound, 
although  the  physiological  narrowing  continues,  the  patient  becomes 
and  remains  well  without  the  necessity  of  further  use  of  instruments 
in  his  urethra. 

Just  within  the  meatus — at  an  eighth  to  a  quarter  of  an  inch — 
there  is  very  often  a  point  of  congenital  narrowing  which  may  be  as- 
sumed to  be  a  stricture,  and  cut  if  there  is  any  occasion  for  using  an 
instrument  larger  than  this  point  of  narrowing  will  admit — otherwise, 
it  may  be  disregarded.  It  is  always  wise  to  divide  it  if  stricture  exists 
beyond,  because  a  free  meatus  greatly  facilitates  the  use  of  large 


132  STRICTURE   OF   THE   URETHRA. 

sounds  and  the  cure  of  deeper  strictures.  Always  vrhcu  there  is  a 
pouched  condition  of  the  meatus  at  the  lower  commissure,  so  that  a 
probe  introduced  within  it  may  be  made  to  catch  upon  withdrawal  at 

right  angles  to  the  axis  of  the  penis — in 
such  cases,  the  meatus  is  certainly  too 
small,  and  for  the  treatment  of  any 
stricture  more  deeply  seated  it  should  be 
cleanly  and  freely  cut  down  ui)on  the 
floor  of  the  urethra  to  facilitate  the  use 
p,^,  3,  of  a  sufficiently  large  sound  afterwards 

(Fig.  51). 
Symptoms  and  Kesults  of  Strictuke. — Stricture  may  exist  for 
years  without  giving  rise  to  a  single  symptom  of  sufficient  importance 
to  attract  the  patient's  attention.  In  fact,  it  may  be  said  that  strict- 
ure has  necessarily  no  symptoms  until  it  has  become  so  tight  as  to 
sensibly  obstruct  the  outflow  of  urine  and  semen,  or  has  been  at- 
tended by  so  much  callous  overgrowth  as  to  interfere  with  the  flow 
of  blood  through  the  meshes  of  the  corpus  spongiosum.  One  may 
have  stricture  of  small  caliber  of  any  part  of  the  canal,  but  espe- 
cially of  the  meatus,  and  yet  never  sufl'er  from  it  in  any  way  until 
adult  life — perhaps  never  at  all.  But,  when  a  tight  point  exists,  al- 
though it  may  have  been  congenital  and  may  never  have  announced 
its  presence  to  the  patient  by  any  subjective  symptom,  yet  if  such  a 
patient  becomes  enfeebled  in  health,  run  down  in  nervous  force, 
acutely  inflamed  upon  the  mucous  surface  of  the  urethra  from  gonor- 
rhoea or  other  cause,  under  stich  circtimstances  the  tight  point  be- 
comes an  clement  of  importance  in  his  case,  and  his  morbid  symptoms 
frequently  will  not  yield  until  this  narrowed  area  is  properly  enlarged. 
All  this  is  especially  true  of  tight  areas  along  the  pendulous  ure- 
thra. A  man  may  be  born  with  them  and  die  with  them  (but  not  of 
them),  and  never  have  a  morbid  symptom  due  to  their  existence. 
Hundreds  of  cases  might  be  cited  in  illustration  of  this  fact,  going  to 
show  that  tight  points  in  the  pendulous  urethra  do  not  necessarily 
cause  any  symptom,  and  perhaps  never  do  produce  symptoms  except 
upon  the  addition  of  some  other  cause.*  Then,  and  not  till  then,  do 
they  require  cutting.  In  short,  wiien  in  examining  a  given  urethra 
one  or  more  points  of  narrowing  are  detected  in  the  pendulous  portion, 
if  these  points  are  not  the  cause  of  the  symptoms  of  which  the  patient 
complains,  there  is,  in  my  opinion,  no  occasion  for  cutting  them.  The 
urethra  is,  I  believe,  as  serviceable  with  them  as  without  them,  and  no 
material  advantage  comes  to  a  healthy  man  after  their  division,  while 
many  morbid  conditions  may  be  removed  without  interfering  with  the 
so-called  strictures  of  large  caliber.  In  cases  of  doubt  and  in  ohsciire 
conditions  of  deep  urethral  and  bladder  trouble  it  is  justifiable  to 

*  Cases  XVIII  and  XIX  of  the  first  edition  of  this  treatise  are  sharply  in  point. 


SYMPTOMS  AND   RESULTS. 


133 


divide  these  points  of  moderate  anterior  narrowing,  as  a  means  of 
more  accurate  diagnosis — as  well  as  to  set  aside  any  possible  agency  of 
the  reflex  irritative  sort  which  these  points  sometimes  seem  to  exercise 
upon  the  deeper  parts  of  the  urethra. 

The  symptoms  usually  described  as  those  of  stricture  are  mainly 
the  symptoms  of  the  results  of  stricture,  and  consequently  a  description 
of  these  latter  finds  its  place  here. 

A  certain  small  amount  of  gleety  discharge  from  the  congested  (or 
it  may  be  granular)  surface  usually  accompanies  the  forming  stage  of 
stricture,  but  this  may  be  so  slight  as  not  to  attract  attention,  or  may 
be  entirely  absent.  Exceptionally  urethral  or  other  neuralgia  depends 
upon  stricture  in  the  forming  stage. 

The  results  of  stricture  are  mainly  mechanical  in  the  first  place. 
The  strictured  portion  is  less  dilatable  than  the  rest  of  the  canal,  and 
acts  somewhat  like  a  dam. 
The  urine  coming  down  with 
great  force,  and  striking 
against  this  unyielding  bar, 
tends  to  dilate  the  urethra 
behind  it  (Fig.  52),  and  this 
directly  in  proportion  as  the 
stricture  is  slow  in  forming 
and  dense  in  structure.  If 
more  than  one  stricture  exist, 
the  urethra  may  be  dilated 
between  them.  This  stretch- 
ing process  tends  to  dilate 
the  mouths  of  all  the  ducts 
opening  into  the  urethra 
behind  a  stricture.  In  this 
way  the  sinuses  and  mouths 
of  all  the  follicles  become 
enlarged,  and  capable  of  en- 
trapping the  point  of  a  fine 
instrument.  This  is  also 
true  of  the  ducts  in  the  pros- 
tatic sinus,  which  may  be- 
come so  pouched  out  that 
the  floor  of  the  prostatic  ure- 
thra becomes  reticulated,  and  composed  entirely  of  depressions,  sej^a- 
rated  by  thin  fibrous  partitions — these  latter  re]3resenting  what  is  left 
of  the  tissue  which  existed  originally  between  the  ducts  of  prostatic 
follicles.  The  ejaculatory  ducts  may  be  distended  in  the  same  way  ; 
as  may  also,  though  rarely,  the  seminal  vesicles — the  urine  being 
forced  back  into  them. 


Fig.  52.— Taken  from  a  patholoffical  specimen,  showing 
stricture  of  membranous  urethra,  with  dihitation  be- 
hind it,  hypertrophy  of  bladder,  dilatation  of  ureters, 
pelvis  of  kidneys,  etc. 


134:  STRICTIKE   OF   THE   URETHRA. 

The  force  exerted  laterally  by  tlie  urine  propelled  through  the 
urethra  by  the  contracting  bladder  js  much  greater  than  is  generally 
supposed.  To  understand  this,  it  is  only  necessary  to  call  to  mind  the 
hydrostatic  paradox,  Avhich  demonstrates  the  equal  pressure  of  Iluids 
ou  every  square  line  of  surface  with  which  they  come  iuto  contact. 
This  forcible  stretching  of  the  mucous  membrane  behind  the  stricture 
at  every  act  of  micturition,  althougli  only  slight  in  extent  at  first, 
Aveakens  the  tone  of  the  stretched  portion  of  the  canal,  congests  it, 
and  leads  to  the  formation  locally  of  an  excess  of  mucus.  If  the  urine 
bo  acid  and  irritating,  these  elTectS  take  place  all  the  more  rai)idly. 
Soon  a  drop  of  urine  is  retained  behind  the  stricture  in  the  dilated 
portion  of  the  canal,  the  mucus  acting  upon  it  as  a  ferment  alkalinizes 
and  decomposes  it,  liberating  carbonate  of  ammonia.  This  acts  upon 
the  stretched  urethra,  and  produces  inflammation.  This  mild  inflam- 
mation behind  stricture  is  very  constant.  It  furnishes  the  gleety  dis- 
charge, or  the  morning  drop  of  muco-pus,  which  glues  the  lips  of  the 
meatus  together. 

The  gleet  of  stricture  gets  better  or  worse  according  to  the  general 
condition  of  the  patient,  the  degree  -of  acidity  of  the  urine,  and  the 
amount  of  sexual  indulgence  or  venereal  excitement.  Exacerbations 
of  gleet  from  slight  causes,  or  repeated  attacks  of  gonorrhcea,  as  the 
patient  usually  considers  them  to  be,  often  constitute  the  most  marked 
feature  of  the  case  in  a  patient  with  stricture.  In  fact,  it  is  the  rule 
in  mild  cases  that  the  patient  is  wholly  unconscious  that  his  urethra 
is  at  all  narrowed.  He  applies  for  treatment,  on  account  of  his  gleet, 
for  an  attack  of  gonorrhcea,  as  he  calls  its  (bastard  gonorrhcea),  and 
often  refuses  to  believe  that  he  has  stricture,  or  that,  if  stricture  does 
exist,  it  is  of  enough  importance  to  occasion  his  symptoms ;  and  he 
repeatedly  asserts  that  he  makes  as  large  a  stream  of  urine  as  ever. 
Nothing  so  well  as  the  bulbous  bougie  will  convince  such  a  patient  of 
his  condition.  The  evidence  of  this  instrument  he  must  admit.  The 
gleety  discharge,  once  commenced  behind  the  stricture,  rarely  ceases 
entirely  until  the  constriction  has  been  relieved.  The  same  dis- 
charge will  be  seen  in  the  urine  in  the  shape  of  small,  stringy  shreds, 
formed  of  pus-corpuscles  which  have  been  washed  off  from  the  con- 
gested surface  upon  and  behind  the  stricture,  and  appear  as  small 
white  threads  in  the  voided  urine.  These  shreds  may  be  all  caught 
in  the  first  gush  of  urine,  what  follows  being  perfectly  free  from  them. 
When  these  white  filaments  are  seen  settling  down  in  a  glass  of  urine 
freshly  passed,  they  constitute  strong  presumptive  evidence  of  the 
existence  of  stricture  ;  they  may  be  due  to  other  lesions. 

As  the  stricture  tightens,  fresh  symptoms  are  added.     A  cartilagi- 

.  nous  hardness  may  often  be  felt  from  the  outside  of  the  urethra  at  the 

constricted  point.     The  meatus  urinarius  looks  blue  and  congested,  as 

does  sometimes  the  whole  glans  penis,  from  obstructed  circulation. 


SYMPTOMS   AND   KESULTS.  135 

t 

The  gleet  continues,  the  stream  of  urine  is  small,  often  forked  or 
curving  uj)  in  a  curious  manner  just  after  leaving  the  meatus,  or  there 
may  be  several  streams  running  in  different  directions,  or  oftener  one 
stream  is  projected  for  a  certain  distance,  while  the  other  drops  down 
perpendicularly  from  the  end  of  the  penis.  The  last  few  drops  of 
urine  are  retained  in  the  canal,  both  mechanically  by  the  obstruction 
of  the  stricture,  and  because  the  wave  of  blood,  impelled  by  the  con- 
traction of  the  accelerator  urinse  upon  the  bulb  in  the  final  effort  at 
clearing  the  canal,  can  not  pass  along  the  corpus  spongiosum,  on  ac- 
count of  the  obliteration  of  its  meshes  at  the  point  of  stricture,  and 
thus  fails  in  its  function  of  expelling  the  last  few  drops  of  urine  from 
the  canal.  By  this  same  obliteration  of  spongy  tissue,  erection  is 
sometimes  rendered  imperfect  and  painful. 

The  surface  congestion  of  the  stretched  urethra  behind  the  strict- 
ure in  time  extends  backward  to  the  bladder,  and  brings  on  irritabil- 
ity (so  called)  of  that  organ.  The  intervals  between  the  acts  of 
micturition  grow  shorter  and  shorter,  and  symptoms  of  mild  cystitis 
appear.  Th\^  frequency  of  micturition  is  the  symptom  of  stricture, 
next  to  gleety  discharge,  which  is  least  often  absent.  A  slight  narrow- 
ing of  the  canal  may  occasion  it,  as  where  the  meatus  is  congenitally 
small,  and  it  may  come  on  with  any  stricture,  as  pure  irritability,  un- 
doubtedly attended  by  congestion  about  the  neck  of  the  bladder,  but 
not  necessarily  by  any  true  cystitis. 

The  congestion  of  the  urethra  behind  a  stricture  easily  becomes 
greater,  is  kindled  into  positive  inflammation  by  dining  out,  a  little 
excess  in  drink,  or  a  chilling  of  the  legs  ;  the  mucous  membrane  swells 
up,  the  stricture  closes,  and  the  patient  has  retention  of  urine.  If 
this  retention  is  unrelieved,  the  bladder  becomes  overstretched  ;  after 
many  hours  a  few  drops  of  urine  will  escape  from  the  meatus  (overflow), 
and  the  patient  thinks  he  is  getting  better.  If  this  condition  of  over- 
distention  is  allowed  to  continue  unrelieved,  the  contractile  power  of 
the  bladder  may  be  permanently  injured  (atony).  Retention  may  he 
the  only  disagreeably  prominent  symptom  connected  with  a  case  of 
stricture. 

The  gleet  may  not  have  been  noticed,  the  gradual  decrease  in  the 
size  of  the  stream  may  have  been  ignored,  when,  after  exposure,  ex- 
cess, a  carouse  of  beer,  retention  suddenly  comes  on.  Some  patients 
will  have  had  several  attacks  of  retention  before  they  apply  for  relief. 
The  spasm  and  inflammation  which  caused  the  narrow  canal  to  become 
obliterated  in  these  cases  cease  after  a  few  hours,  and  then  the  patient 
goes  on  perhaps  for  a  year  or  more,  without  having  another  retention, 
not  suffering  noticeably  in  the  mean  time. 

If  retention  does  not  come  on,  the  inflammation,  once  aroused  be- 
hind stricture,  gradually,  sometimes  rapidly,  travels  back  through  the 
prostatic  urethra  into  the  bladder,  and  we  have  cystitis  of  the  neck. 


130  STRICTURE   OF  THE   URETHRA. 

Now  commences  what  was  before  absent,  or,  if  present,  only  to  a  mild 
doirree,  a  frequent  desire  to  pass  water,  at  first  every  three  or  four 
hours,  once  at  night,  and  gradually  at  shorter  and  shorter  intervals, 
until,  when  the  patient  seeks  relief,  he  may  be  passing  water  in  a 
fine  stream  every  half-hour  or  tiftccu  minutes,  with  great  pain  and 
straining. 

Blood  sometimes  Hows  with  the  urine  at  the  beginning  or  end  of 
the  act.  HcBmaturia  may  be,  excei)tionally,  the  most  })rominent  symp- 
tom of  stricture,  indeed  the  only  one  noticed  by  the  patient  for  a  long 
time.  I  have  had  several  such  cases,  and  have  seen  the  hsematuria 
c?ase  upon  relieving  the  stricture. 

Along  with  symptoms  of  vesical  irritation,  often  before  any  actual 
inflammation  of  the  bladder  has  occurred,  are  found  pains  various  in 
character  and  situation.  Pain  in  the  urethra,  aching  of  the  glans  penis, 
or  in  the  testicle,  along  the  cord  running  up  into  the  back.  Pains  across 
the  lumbar  region,  in  the  periuanim,  around  the  anus,  and  in  the  rec- 
tum, over  the  pubis,  etc.,  and  other  obscure  pains  of  a  neuralgic  sort, 
in  the  thighs,  legs,  or  in  the  sole  of  the  foot*  (Brodie),  all  of  which 
pains  are  cured  by  the  dilatation  of  the  stricture.  Urination  is  often 
painful  (sometimes  excessively  so),  the  pain  being  at  the  neck  of  the 
bladder,  in  the  perinseum,  at  the  point  of  stricture,  or  near  the  glans 
penis.  Erections  may  be  painful,  the  venereal  orgasm  attended  by 
pain,  the  semen  not  being  discharged  during  the  sexual  act,  but  often 
dribbling  away  afterward,  perhaps  stained  with  blood,  or  running  back 
into  the  bladder,  to  be  discharged  at  the  next  flow  of  urine.  Impo- 
tence sometimes  accompanies  this  condition.  The  sexual  appetite  is 
often  impaired,  sometimes  nearly  obliterated,  in  old  severe  cases.  But, 
in  mild  cases,  the  congestion  kept  up  behind  the  stricture  may  be  just 
enough  to  excite  and  irritate  the  patient,  causing  frequent  erections, 
erotic  fancies,  nocturnal  emissions. 

The  constant  straining  in  urination  keeps  the  hjcmorrhoidal  vessels 
congested.  This  results  not  unfrequently  in  an  attack  of  piles,  or  of 
prolapse  of  the  rectum  ;  occasionally,  hernia  occurs  from  the  same 
cause.  The  straining  may  be  so  violent  that  the  bowel  will  protrude  at 
every  effort  to  empty  the  bladder,  making  it  unsafe  for  the  patient  to 
attempt  to  urinate  except  upon  a  close-stool,  for  fear  of  the  passage  of 
faeces  at  the  same  time  with  the  flow  of  urine. 

The  inflammation  of  the  bladder  caused  by  stricture  is  usually  su- 
perficial, but  it  may  become  parenchymatous,  perhaps  accompanied  by 
abscess  in  the  walls  of  the  bladder,  or  in  the  connective  tissue  around 
it.  The  bladder-walls,  as  a  rule,  thicken,  while  their  dilatability  di- 
minishes, in  cases  of  stricture.  The  detrusor,  constantly  called  upon 
to  force  the  urine  through  a  narrow  orifice,  becomes  thickened  and 

*  Or  in  the  great  toe.  The  pain  is  sometimes  compared  to  intense  heat,  sometimes  to 
icy  coldness,  sometimes  it  is  actual  pain  over  a  given  small  area.     (See  Pododynia.) 


SYMPTOMS   AND   llESULTS.  137 

liyperfcropliied,  sometimes  to  the  extent  of  one  half  or  tlirce  quarters 
of  an  inch. 

Trabeculae  of  muscular  tissue  project  upon  the  mucous  surface  of 
the  bladder,  and  between  these  trabcculae  the  mucous  membrane  maj 
protrude,  forming  pouches  or  sacculi.  The  bladder  may  contract  to 
such  an  extent  as  to  have  its  cavity  almost  totally  obliterated,  its  mus- 
cular walls  having  undergone  fibrous  degeneration,  which  has  rendered 
them  non-distensible.  In  this  condition  (concentric  hypertrophy)  we 
may  have  a  constant  flow  of  urine  from  the  urethra,  which  the  patient 
cannot  control  (incontinence),  to  be  carefully  distinguished  from  atony, 
with  overflow. 

Instead  of  incontinence,  in  this  condition,  the  patient  may  be  ob- 
liged to  empty  his  bladder  every  few  minutes,  after  a  few  drachms  of 
urine  have  accumulated,  which  seem  to  be  bursting  the  organ.  The 
urinary  salts  sometimes  deposit  in  vesical  sacculi,  or  a  small  renal  cal- 
culus lodges  there,  forming  a  nucleus  for  stone.  The  more  obstruction 
there  is  in  the  urethra,  the  more  pressure  is  brought  to  bear  upon  the 
sacculi,  and  the  larger  they  become,  so  that  sometimes  they  equal,  or 
exceed,  the  size  of  the  cavity  of  the  bladder.  As  the  sacculus  enlarges, 
its  neck  remains  constant,  and,  if  stone  form  in  it,  the  stagnant  urine 
(for  there  is  no  surrounding  muscular  tissue  to  empty  it)  furnishes 
constantly  fresh  supplies  of  urinary  salts  to  increase  the  size  of  the 
stone,  so  that  finally  the  latter  may  fill  up  the  sacculus,  constituting 
what  is  known  as  encysted  calculus. 

Instead  of  contracting,  the  bladder  may  (rarely)  dilate.  In  these 
cases  there  has  not  been  so  much  irritability,  and  the  bladder  has  not 
been  called  into  such  constant  use  ;  or  overstretching  may  have  been 
followed  by  atony,  in  which  case  overflow  occurs,  apt  to  be  mistaken 
for  incontinence.  Inflammation  of  the  mucous  membrane  is  found, 
in  these  cases  of  eccentric  hypertrophy  also,  together  with  the  tra- 
beculse  of  hypertrophied  muscular  tissue  and  the  sacculi. 

These  conditions  of  vesical  and  urethral  irritation,  or  others,  such 
as  stone,  are  sometimes,  but  very  rarely,  attended  by  partial  paralysis 
of  some  groups  of  muscles  of  the  lower  extremities,  or  indeed  by  para- 
plegia. These  paralyses  have  received  the  name  of  reflex  urinary 
paralysis,  and  seem  to  depend  upon  the  morbid  condition  of  the  uri- 
nary organs,  and  to  be  relievable,  sometimes  even  curable,  by  treat- 
ment of  the  urinary  difficulty.*  Not  very  infrequently  mild  syphilitic 
paraplegia  is  mistaken  for  urinary  reflex  paralysis,  especially  if  the 
urethra  or  bladder  happen  to  show  any  trifling  lesion. 

The  urine,  in  cases  of  cystitis  caused  by  stricture,  is  partly  decom- 
posed and  filled  with  blood,  pus,  crystals,  etc.,  as  occurs  in  cystitis 

* Brown-Sequard,  "Lecture  on  Reflexed  Paraplegia,"  "Lancet,"  1863;  and  "Lec- 
tures on  the  Diagnosis  and  Treatment  of  the  Principal  Forms  of  Paralysis  of  the  Lower 
Extremities,"  Philadelphia,  1861. 


138  STRICTURE   OF   THE   URETHRA. 

from  otlior  causes.  Phosi)luitic  stono  may  form.  The  ureters  eularc:e 
in  connection  with  old  stricture,  sometimes  to  the  size  of  tlie  thumb. 
Their. walls  become  unevenly  thickened  and  their  caliber  enormously 
increased  by  the  constantly  retained  urine.  The  pelves  of  the  kidne3's 
undergo  the  same  distention,  the  tubuli  and  secreting  jiortions  being 
jnished  out  and  compressed  by  tlie  accumulating  urine.  After  the  in- 
liammaticui  at  the  neck  has  involved  the  whole  internal  surface  of  the 
bladder,  it  may  extend  up  the  ureters  and  enter  the  pelves  of  the  kid- 
neys, bringing  on  pyelitis,  or  attack  the  secreting  portion  as  a  subacute 
nephritis  with  more  or  less  suppression  of  urine,  attended  by  symptoms 
of  urannia.  Finally,  and  more  rarely,  may  be  mentioned  abscess  of 
the  kidney  with  perinephritis. 

ExTRAVASATioisr. — The  thinned  and  inflamed  urctiira  behind  stric- 
ture may  ulcerate,  and,  during  one  of  the  violent  paroxysms  of  strain- 
ing, give  way,  and  allow  a  little  urine  to  escape  into  the  cellular  tissue 
around  the  canal.  The  patient  is  often  conscious  of  something  having 
"broken  "  in  the  urethra.  The  amount  of  extravasated  liquid  may  be 
very  small,  or  a  sudden  gush  of  urine  is,  perhaps,  let  out  into  the  con- 
nective tissue.  In  the  former  case  we  have  abscess,  or  perhaps  blind 
internal  fistula,  which  may  continue  as  such  for  many  months.  Its 
presence  is  indicated  by  a  hard  lump  around  the  urethra,  varying 
from  the  size  of  a  large  pea  to  that  of  an  English  walnut,  usually  sen- 
sitive to  pressure,  sometimes  slightly  painful  at  each  act  of  micturitiou. 
This  hard  lump  more  or  less  rapidly  enlarges,  though  it  may  remain 
stationary  for  an  indefinite  jieriod,  or  even  decrease  in  size  ;  urethral 
fever  comes  on,  generally  described  by  the  patient  as  "dumb  ague"  ; 
the  appetite  fails,  and  the  general  health  runs  down  ;  finally,  pus 
forms  and  finds  its  way  out  through  the  perinanim,  leaving  a  fistula 
behind.  Instead  of  this  slow  course,  if  the  quantity  of  urine  which 
escapes  is  a  little  larger,  acute  perineal  abscess  forms. 

The  pus  may  burrow  in  all  directions,  and  finally  find  an  exit 
through  the  scrotum,  along  the  body  of  the  penis,  upon  the  thighs, 
nates,  or  groins,  or  even  upon  the  lower  part  of  the  abdomen.  Some- 
times the  whole  perinseum  is  riddled  with  holes  through  which  the 
urine  escapes,  perhaps  not  one  drop  passing  by  the  natural  channel. 
In  these  cases  the  patient  makes  water  sitting,  the  urine  escaping  as 
if  through  the  sprinkler  of  a  garden  watering-pot.  Civiale  rej^orts  a 
case  of  urinary  fistula  with  fifty-two  external  openings. 

The  hard  lumps  outside  the  urethra,  above  alluded  to,  do  not 
necessarily  indicate  that  urine  has  escaped  from  the  canal.  An  ab- 
scess may  very  rarely  start  outside  the  urethra  near  a  stricture,  just 
as  pus  may  form  near  the  anus,  not  primarily  in  connection  with  the 
gut.  In  the  vast  majority  of  these  cases,  however,  the  first  lesion  is 
upon  the  urethral  mucous  membrane,  one  of  the  dilated  follicles  be- 
hind the  stricture  being  at  fault.     A  drop  of  urine  is  retained  in  a 


EXTRAVASATION.  139 

follicle,  decomposes,  and  causes  it  to  necrose  and  Blou;,^h  ;  another 
drop  of  urine  is  then  let  in,  more  tissue  is  destroyed,  and  more  inflam- 
matory action  set  up  in  the  neighboring  tissue.  This  process  goes 
slowly  on,  a  drop  of  urine  from  time  to  time  being  let  into  the  abscess 
througli  the  mouth  of  the  follicle,  which  is  usually  kept  shut  by  the 
surrounding  inflammatory  swelling.  The  abscess  now  is  not  connected 
visibly  with  the  urethra  ;  it  breaks  externally,  and  it  is  only  after  a 
few  days  that  the  swelling  decreases  sufficiently  to  allow  a  little  urine 
to  get  in  at  the  fissure  in  the  urethral  wall,  and  to  appear  at  the  peri- 
neal opening.  Much  light  has  been  thrown  by  Zcissl  upon  the  agency 
of  this  follicular  necrosis  in  allowing  extravasation  of  urine.  Such 
abscesses  forming  around  stricture  may  break  internally  and  let  in  the 
urine  in  quantity,  thus  forming  blind  internal  fistula,  or  they  may 
break  externally,  or  point  by  both  routes. 

Fistulse  are  conservative  efforts  of  Nature  to  establish  an  outlet  for 
the  urine,  the  natural  course  being  dammed  up.  They  will  not  close 
until  after  the  stricture  has  b.een  relieved.  They  narrow  down  after  a 
while  into  little  pipes  surrounded  by  callous  inflammatory  material. 
Sometimes  a  deposit  of  the  urinary  salts  takes  place  upon  their  walls, 
and  they  become  incrusted  with  calcareous  matter.  Sometimes  they 
get  blocked  up,  especially  if  the  internal  orifice  is  larger  than  the  ex- 
ternal ;  then  a  little  urine  collects  within  them,  and  a  new  abscess  is 
formed  which  may  burrow  farther  and  find  for  itself  a  new  outlet, 
establishing  another  fistula.  More  rarely  a  small  abscess  may  form  in 
the  prostate,  and,  going  through  the  stages  just  narrated,  opening 
into  the  urethra  and  into  the  rectum,  constitute  what  is  known  as 
prostatic  fistula  ;  or,  more  rarely  still,  some  small  ulceration  in  the  floor 
of  the  bladder  may  give  way  into  the  rectum,  making  a  vesico-rectal 
fistula. 

If,  instead  of  a  drop  of  urine  escaping  from  the  urethra  into  an 
ulcerated  follicle  or  fissure  in  an  ulcer  behind  the  stricture,  the  ulcer- 
ated portion  has  given  way  largely,  perhaps  by  necrosis  of  a  group  of 
urethral  follicles,  we  have  the  serious  complication  known  as  infiltra- 
tion of  urine.  More  or  less  of  the  altered  fluid  escapes  in  these  cases 
outside  of  the  canal,  and  burrows  at  once  extensively.  It  is  a  prop- 
erty of  decomposed  ammoniacal  urine  to  destroy  the  vitality  of  living 
tissue  wherever  it  comes  into  contact  with  it,  unprotected  by  e^nthe- 
lium.  This  property  does  not  belong  to  limpid  healthy  urine.  Men- 
zel  *  demonstrated  this  fact  experimentally.  He  first  used  acid  urine, 
injecting  it  under  the  skin  of  a  dog  in  quantities  varying  from  a 
drachm  to  an  ounce  without  any  bad  effect  in  several  experiments. 
He  dissected  up  the  skin  of  a  dog  to  the  breadth  of  four  inches,  and 
injected  eight  ounces  of  healthy  human  urine  in  four  different  cases. 

*"Wien.  medizin.  Wochenschrift,"  Nos.  Sl-85,  1869,  and  "K  T.Med.  Journal," 
1871. 


140  STRICTURE   OF   THE   URETHRA. 

The  urine  was  all  absorbed  within  four  days  in  three  of  tlie  cases,  in 
the  other  liealthy  pus  formed,  lie  repeated  these  exjieriments  in  the 
ischio-rectal  fossa  without  bad  results  in  five  cases.  To  test  the  o})inion 
of  Simon,*  that  the  compression  with  distention  of  the  tissues  in  urin- 
ous infiltration  was  the  cause  of  gangrene,  Menzel  performed  two  ex- 
periments, injecting  healthy  urine  into  the  tissues  with  such  force  as  to 
raise  a  tumor  of  the  size  of  the  fa^tal  head,  and  then  prevented  the 
escape  of  the  fluid  through  the  wound  by  means  of  suture.  The  quan- 
titv  injected  amounted  to  about  half  a  pint,  but  in  both  cases  it  was 
absorbed  without  evil  result  within  three  days. 

The  next  experiment  consisted  in  cutting  down  upon  the  urethra 
of  a  dog  and  sewing  up  the  wound  so  as  to  obtain  intiltration.  At 
each  angle  of  the  wound  a  fistula  formed,  but  there  was  no  poisoning 
or  extensive  death  of  tissue.  lie  repeated  the  same  experiment,  tying 
the  glans  penis  so  as  to  cause  all  the  urine  to  flow  into  the  wound. 
An  immense  tumor  formed,  which  only  subsided  when  the  glans  penis 
became  gangrenous  and  separated.  The  dog  got  well,  with  simply  a 
fistula.     In  other  similar  cases  he  obtained  the  same  results. 

From  these  experiments  Menzel  concluded  : 

1.  That  normal  urine  does  not  possess  septic  qualities,  and  does  not 
produce  gangrene  by  its  chemical  properties. 

2.  That  distention  by  infiltrated  urine  does  not  produce  gangrene. 

3.  That  gangrene,  when  it  docs  occur  (on  infiltration  of  healthy 
urine),  is  caused  by  contusion  or  the  accidental  inoculation  of  septic 
matter. 

Menzel  next  experimented  with  urine  containing  soda  or  potash. 
Urine  so  alkalinized  proved  innocuous  ;  but  urine  rendered  alkaline 
by  ammoniacal  fermentation  he  found  to  be  exceedingly  poisonous, 
and,  when  injected,  to  cause  large  abscesses  and  cutaneous  gangrene. 
lie  also  injected  putrid  urine  directly  into  the  blood,  and  obtained 
symptoms  of  blood-poisoning,  lie  further  adds  the  clinical  experience 
of  Prof.  Billroth  in  nine  cases  of  infiltration.  In  l^ne,  the  urethra 
was  perforated  by  a  catheter  ;  in  three,  there  was  a  crushing  injury  to 
the  perineum  ;  in  another,  laceration  of  the  urethra  by  a  splinter  of 
bone  from  the  pelvis ;  in  the  rest,  rupture  of  the  urethra  behind  a 
stricture.  Death  followed  in  four  cases,  in  two  of  which  there  was 
stricture,  and  the  urine  i)robably  ammoniacal, 

A  most  instructive  scientific  discussion  as  to  the  cause  of  the  fer- 
mentation of  urine  is  to  be  found  in  the  admirable  thesis  of  F.  P. 
Guiard,t  and  many  new  and  interesting  facts  about  the  toxic  quali- 
ties of  normal  urine  in  Bouchard's  admirable  contribution  J  to  the 
subject.     Bouchard  experimented  upon  rabbits  by  injecting  normal 

*  "  Chinirjrie  dcr  Nieren." 

f  "  La  Transformation  ammoniacal  des  Urines,"  Tln^se,  Paris,  1883. 

\  "Gazette  Ilebd.,"  1886,  vol.  xxxiii,  Nos.  13  and  14,  pp.  205-221. 


EXTRAVASATION.  14]^ 

heulthy  urine  into  a  vein.  An  injection  of  two  to  three  draclims 
caused  contraction  cf  the  pupils,  shallow,  hurried  respiration,  and 
finally  death  with  reduction  of  temperature  and  of  reflex  activity. 
Bouchard  believes  that  in  two  days  and  four  hours  a  man  eliminates 
enough  poison  to  destroy  himself — were  it  i)roperly  applied.  lie  finds 
diurnal  urine  to  possess  narcotic  properties,  the  night  urine  to  be  less 
poisonous  than  the  diurnal  secretion,  but  to  cause  cramps  and  convul- 
sions.    He  is  still  investigating  this  interesting  subject. 

But,  notwithstanding  all  this,  the  fact  remains  that  so  far  as  the 
local  death  of  tissue  is  concerned,  while  ammoniacal  and  putrid  de- 
composing urine  is  deadly  in  its  effect,  healthy  urine,  in  moderate 
quantity,  at  least,  is  readily  absorbed  by  the  tissues,  and  does  not  lead 
to  local  inflammation  or  death  of  tissue.  My  house-surgeon.  Dr.  Par- 
tridge, made  for  me  many  experiments  by  injecting  healthy  urine  acid 
and  alkaline  (not  ammoniacal)  into  the  subcutaneous  tissues,  using  as 
much  as  sixty  minims  at  a  single  injection.  No  abscess  was  ever 
caused  by  these  injections  ;  absorption  was  perfect.  Feltz  and  Ritter* 
have  injected  enormous  doses  of  urea  into  dogs  without  damage,  unless 
some  of  the  salts  of  ammonia  are  combined  with  the  urea.  There 
appears  to  be  no  normal  ferment  in  the  blood  capable  of  transforming 
urea  into  ammoniacal  salts.  Pasteur  f  overthrew  Bastian's  experi- 
ments, and  showed  that  without  bacteria  urine  does  not  decompose. 
Pasteur  and  Joubert,  J  repeating  some  of  the  experiments  of  Musculus, 
show  that  the  soluble  ferment  produced  by  the  latter  from  ammoniacal 
urine,  which  is  capable  of  changing  urea  and  water  into  carbonate  of 
ammonia,  is  the  product  of  bacteria.  P.  Cazenave  and  Ch.  Livon 
ligated  a  dog's  prepuce,  allowed  the  dog  to  die,  tied  the  ureters  and 
urethra,  removed  the  bladder,  and  kept  it  exposed  to  air  for  several 
days  at  temperatures  varying  from  80°  to  122°  Fahr.  The  urine  did 
not  decomjDOse,  and  no  organisms  apj^eared  in  it. 

These  results,  experimental  and  clinical,  correspond  with  daily  e'x- 
perience  as  well  as  with  my  personal  experiments  undertaken  upon  the 
human  subject — since  the  evidence  derived  from  dogs*  and  rabbits 
has  been  doubted — to  substantiate  the  fact  that  healthy  urine,  in- 
jected into  the  connective  tissue  without  contusion  of  that  tissue,  is 
as  capable  of  absorption  as  the  blandest  fluid.  This  is  true  at  least 
when  a  small  amount  is  used  ( 3  j),  a  quantity  certainly  sufficient  to 
establish  that  healthy  urine,  per  se,  is  not  destructive  to  human 
tissues.     Muron,||  a  pupil  of  Verneuil,  stimulated  seemingly  by  the 

*  "La  France  Med.,"  May  11,  1878. 

f  "  Comptes  rendus  de  I'Acad.  des  Sciences,"  July  23,  1877. 

X  "Journal  de  Pharmacie  et  de  Chimie,"  September,  1876,  p.  206. 

*  Dr.  L.  A.  Stimson  informs  me  that,  in  the  winter  of  1873,  he  saw  Yulpian,  in  Paris, 
inject  healthy  human  urine  into  the  blood-vessels  of  dogs,  in  one  case  three  and  one-half 
ounces,  without  disagreeable  result. 

II  "  Pathogenic  de  I'lnfiltration  de  I'Urine,"  Paris,  1872. 


142  STRICTURE   OF   THE   rRETIIRA. 

results  obtained  by  ^lonzel.  i)ci-fonnod  a  scries  of  experiments  by  in- 
jecting urine  under  tiie  skin  of  rabbits.  His  results  corresponded 
closely  to  those  reached  by  Menzel,  only  differing  in  one  respect :  for, 
while  Menzel  states  that  only  urine  in  alkaline  fermentation  has  de- 
structive powers,  Muron  proved  (upon  rabbits)  that  urine,  strongly 
acid,  dense,  and  full  of  salts,  urates,  etc.,  has  the  same  powers  to  a 
less  degree,  attributable,  he  believes,  to  the  density  of  the  fluid  in- 
jected, wliich  by  the  law  of  osmosis  attracts  serum  from  the  vessels 
instead  of  itself  being  absorbed  into  the  latter ;  and  again  to  the  fact 
that  urine,  rich  in  urates,  is  apt  to  decompose  quickly.*  Gossclin  and 
A.  Robin  f  conclude  from  experiments  that  acid  normal  urine,  sj).  gr. 
1023,  is  innocuous  wheu  injected  into  rabbits,  although  it  may  kill  if 
continuously  injected  for  a  number  of  days. 

Hence  it  may  be  affirmed  that  healthy  urine  does  not,  per  se,  kill 
tissue,  unless  that  tissue  be  contused  and  inflamed  (absorption  thus 
prevented  and  urine  allowed  to  decompose  in  situ),  and  that,  Avith  in- 
filtration relieved  by  free  incision,  tlie  prognosis  is  vastly  better  if  the 
bladder  were  previously  healthy.  After  urethrotomy,  and  operations 
for  stone,  how  rare  is  infiltration,  when  the  urine  is  comparatively 
healthy  and  has  a  chance  to  escape,  although  it  passes  over  a  raw  sur- 
face on  its  way  out !  The  practical  deduction  from  the  above  is,  to 
let  out  urine  as  soon  as  it  has  extravasated,  and  the  chances  are  that 
serious  gangrene  may  be  averted  unless  the  urine  was  strongly  am- 
moniacal  and  decomposed  before  its  escape,  which  is,  unliapjiily,  too 
often  the  case. 

In  infiltration  the  urine  may  take  any  one  of  five  directions  : 

1.  It  may  when  small  in  quantity  get  out  of  the  urethra,  but  not 
penetrate  Buck's  fascia  (p.  3),  in  which  case  it  may  long  remain  con- 
fined to  one  spot  in  the  perinaBum  as  a  hard,  rounded  swelling — like 
the  blind  internal  fistula  already  described. 

2.  It  may  find  its  w^ay  rapidly  through  the  meshes  of  the  corpus 
s])ongiosum  and  cause  gangrene  of  that  bod}^  with  sloughing  of  the 
glans  penis,  preceded  by  coldness  and  the  a]")pearance  of  a  black  spot 
upon  the  glans. 

*  That  Muron  is  incorrect  in  ascribing  nccessarili/  destructive  properties  to  dense  acid 
urine,  rich  in  urates,  I  thinli  must  be  granted.  I  obtained  a  specimen  of  urine  from  a 
child  with  acute  inflammatory  rheumatism.  It  was  strongly  acid,  sp.  gr.  1040,  and  de- 
posited, on  cooling,  a  dense  precipitate  of  pink  urates  which  equaled  one  fourth  of  the 
volume  of  the  liquid.  A  portion  of  this  was  taken  a  few  hours  after  being  passed,  warmed 
until  the  urates  dissolved,  and  injected  by  Dr.  Partridge,  of  the  Charity  Hospital,  into  the 
subcutaneous  tissue  of  the  arm,  in  three  patients,  half  a  drachm  being  used  in  each  case ; 
absorption  was  immediate  and  perfect.  Twenty-four  hours  afterward  three  other  patients 
were  similarly  injected  from  the  same  specimen,  with  the  same  dose  (  3  ss  each) — only  the 
urine  was  injected  cold  with  the  urates  in  precipitation.  The  bottle  was  shaken  and  the 
fluid  resembled  pea-soup.  A  little  tenderness  on  pressure  for  a  few  hours  marked  the 
spot  of  the  injection,  but  absorption  was  prompt  and  complete  in  each  case,  without  any 
suppuration.  f  "L'Urine  ammoniacal  et  la  Ficvrc  urincuse,"  Paris,  IS'74,  p.  39. 


EXTRAVASATION.  143 

■  3.  It  may  burrow  inside  of  Buck's  fascia,  but  outside  of  the  cor- 
pus spongiosum,  forming  a  fistula  opening  behind  the  glans  penis  or 
on  the  back  of  the  penis  near  its  root,  a  hard  ridge  marking  the  course 
of  the  fistula  within  Buck's  fascia. 

4.  It  may  escape  behind  the  triangular  ligament  into  the  cavity  of 
the  pelvis. 

5.  It  may  escape  outside  of  tlie  common  fascia  of  the  penis,  in  front 
of  the  triangular  ligament ;  in  whioh  case  it  rapidly  distends  the  peri- 
nseum,  the  scrotum,  and  the  connective  subcutaneous  tissue  of  the 
penis,  and  mounts  up  over  the  abdomen,  and  may  also,  more  rarely, 
perforate  the  deeper  layer  of  the  superficial  perineal  fascia,  and  de- 
scend upon  the  thighs. 

When  extensive  infiltration  of  this  sort  occurs,  all  the  parts 
affected  become  cedem.atous  ;  gases  form  in  the  connective  tissue, 
causing  emphysema,  and  making  the  tissues  crackle  when  pressed 
by  the  finger.  Dark  spots  soon  appear,  indicating  gangrene,  and 
extensive  portions  of  tissue  may  slough  away  unless  relief  be  promptly 
afforded. 

The  constitutional  symptoms  are  those  of  shock.  A  chill  usually 
occurs,  followed  by  great  depression ;  a  cold,  clammy  skin  ;  feeble, 
quick,  irregular  pulse  ;  hurried  respiration  ;  furred  tongue  ;  complete 
anorexia  ;  symptoms  of  septicaemia,  and  death. 

When  the  urine  escapes  behind  the  triangular  ligament,  which  it 
does  more  rarely,  it  infiltrates  deeply  around  the  prostate  and  rectum 
well  back  in  the  perinseum,  around  the  bladder  and  up  behind  the 
pubis,  forming  abscess  in  the  cellular  tissue  of  the  hypogastrium,  or 
perhaps  deep  pelvic  abscesses. 

Rupture  of  Bladder. — Another  very  rare  complication  of  stricture 
analogous  to  infiltration  is  rupture  of  the  bladder.  This  occurs  in  the 
same  manner  as  the  escape  of  urine  from  the  urethra  behind  a  strict- 
ure. A  comparatively  healthy  bladder  will  not  rupture  from  retention 
(unless,  of  course,  mechanical  violence  is  added — as  a  fall).  It  will 
become  immensely  distended,  and  then  be  relieved  by  drops  (overflow) 
through  the  urethra,  the  latter  never  being  totally  impervious  to  fluid, 
if  time  is  allowed  for  inflammation  and  spasm  to  subside,  and  enough 
continued  pressure  is  brought  to  bear  upon  it  from  within.  In  those 
rare  cases,  however,  where  a  sacculus  has  become  thinned,  or  an  ulcer- 
ation exists,  the  bladder  may  give  way  under  the  pressure  of  disten- 
tion from  retention,  and  the  urine  escapes  into  the  peritoneal  cavity. 
The  vesical  tumor  subsides.  A  fatal  collapse  usually  soon  closes  the 
scene.*  The  urine  may  escape  into  the  sub-peritoneal  tissue,  giving 
symptoms  like  those  of  infiltration  behind  the  triangular  ligament. 
The  rarity  of  rupture  of  the  bladder  in  connection  with  stricture  is 
shown  by  the  few  cases  reported.  Thompson  says  he  never  saw  it, 
*  For  treatment,  see  Rupture  of  Bladder. 


144  STRICTURE   OF  THE   URETHRA. 

and  quotes  Sir  Everard  Homo  as  having  observed  only  two  cases. 
Pitha  refers  to  a  ease.  * 

The  prostatic  urethra  is  necessarily  liyperannie,  if  not  inflamed 
behind  a  tiglit  stricture,  but,  besides  this,  the  substance  of  the  prostate 
may  undergo  interstitial  inflammation  (abscess).  The  inllammation 
may  extend  down  the  ejacnlatory  ducts,  seize  upon  the  seminal  vesi- 
cles, or,  usually  passing  farther,  involve  the  epididymis. 

Epididymitis  is  a  very  common  complication  of  stricture.  It  may 
affect  one  or  both  sides,  is  usually  very  mild  in  character,  and  leaves 
behind  a  good  deal  of  knotty  induration,  which  is  slow  in  disai)i)ear- 
ing,  and  may  block  up  the  canal  and  entail  subsequent  sterility.  A 
certain  amount  of  hypertrophy,  with  induration  of  the  penis,  and 
some  oedema  of  the  prepuce,  is  an  occasional  complication  of  striciure. 
Civiale  accounts  for  these  symptoms  by  the  straining  in  urination, 
which  prevents  the  return  of  venous  blood,  and  keeps  the  penis  con- 
gested.    It  is  more  often  due  to  lymphangitis. 

Constitutional  Distcebance. — The  constitutional  disturbance 
in  stricture  is  very  variable.  Just  as  one  patient  may  have  cystitis 
from  an  amount  of  contraction  not  capable  of  sensibly  diminishing 
the  size  of  his  stream,  while  another  with  a  stricture  only  pervious  to 
a  filiform  bougie,  used  with  care,  may  pass  limpid  urine  not  more 
than  three  or  four  times  daily,  so  also  does  the  constitutional  sympa- 
thy vary.  As  a  rule,  the  latter  depends  upon  the  complications  of 
stricture  ;  and  a  patient  with  very  tight  stricture,  uncomplicated, 
may  enjoy  robust  health.  When,  however,  the  urethra  behind  a  strict- 
ure begins  to  inflame,  and  the  bladder  to  show  symptoms  of  congestion 
of  the  neck,  and  cystitis  ;  when  paroxysms  of  urethral  fever  become 
frequent  ;  when  epididymitis  and  abscess  come  on,  then  the  whole 
organism  shows  signs  of  distress.  The  appetite  and  strength  fail,  the 
skin  becomes  dry,  pale,  and  harsh,  the  mouth  coated  and  shiny,  and 
the  patient  runs  down  to  a  shadow,  a  living  picture  of  misery,  while 
his  main  business  in  life  is  to  pass  water. 

Causes  of  Death  in  Stricture  Cases. — Stricture  is  not  often 
fatal,  except  in  neglected  cases,  such  as  are  sometimes  encountered  in 
hospitals.  Death  occurs  in  various  ways.  Not  to  mention  the  rare 
cases  of  sudden  death  following  the  simple  introduction  of  an  instru- 
ment, and  only  alluding  to  rupture  of  the  bladder,  and  death  follow- 
ing surgical  operations  for  the  relief  of  stricture,  the  causes  of  fatal 
termination  in  cases  of  stricture  are  three  : 

1.  Extravasation  of  urine,  which,  if  extensive,  kills  at  once  by 
shock,  or,  later,  by  exhaustion  ;  and  blood-poisoning  with  suppura- 
tion, abscess,  gangrene,  pya?mia. 

2.  Uraemia,  from  implication  of  the  kidneys,  by  the  extension  of 
inflammation  up  the  ureters. 

*  Quoted  from  "  Mem.  dc  la  Soc.  Chir.,"  iii,  3,  1853. 


RECAPITULATION   OF   SYMPTOMS.  145 

3.  Cachexia  and  exhaustion,  attended  by  pain,  loss  of  rest,  and 
inability  to  eat,  due  to  the  torment  of  constant  unrelioved  desire  to 
urinate,  and  the  agony  and  labor  of  the  act.  No  more  pitiable  sight 
can  be  imagined  than  that  of  a  man  with  pericystitis,  trying  to  pass 
water  evei-y  five  minutes  through  an  old  tight  stricture.  Standing  up, 
with  his  body  bent  forward,  his  head  leaning  against  the  wall,  or  on 
his  knees,  and  half  doubled  up,  his  hands  clutching  at  any  thing 
within  reach,  he  writhes  and  groans  in  agony,  the  sweat  starting 
from  his  face,  his  whole  body  quivering  and  convulsed  with  pain. 
After  a  minute  of  this  torture,  he  finds  he  has  passed,  perhaps,  a  tea- 
spoonful  of  bloody,  purulent,  putrid  urine,  perhaps  nothing  at  all, 
and  he  sinks  exhausted  upon  his  bed,  only  to  renew  the  effort  after 
five  or  ten  minutes.  No  man  can  long  endure  torture  of  this  sort.  If 
the  surgeon  does  not  soon  bring  him  relief,  death  will  be  more  kind. 

Recapitulation  of  Symptoms  op  Steictuee.— The  si/mjjtoms  of 
stricture  are,  briefly,  narrowing  of  the  canal,  with  dilatation  of  tlie 
urethra  behind,  blueness  of  the  meatus,  irregularities  in  the  stream  of 
urine,  shreds  of  pus-corpuscles  in  the  urine,  pain,  neuralgia  of  the 
urethra,  retention  of  urine,  overflow,  dribbling,  imperfect  erection, 
irritability  of  the  bladder,  haematuria,  impotence — from  urethral  ob- 
struction to  escape  of  semen.  The  reynoter  results  of  stricture  are 
cystitis,  with  various  inflammatory,  functional,  and  structural  changes 
in  the  bladder,  ureters,  kidneys,  rectum,  often  terminating  fatally ; 
stone  in  the  bladder,  infiltration,  perineal  abscess,  fistula,  rupture  of 
bladder,  epididymitis,  and  sterility — from  obliteration  of  the  canal  of 
the  epididymis. 

A  word  must  be  said  here  concerning  the  effect  of  the  sexual  ele- 
ment in  aggravating  the  symptoms  of  stricture.  This  is  especially 
true  concerning  all  painful,  neuralgic,  and  functional  disturbances. 
An  unmarried  man  frequently  tortures  himself  with  fancied  ailments, 
which  he  ascribes  to  sti'icture  ;  or  declares  himself  strictured  when  the 
canal  is  sound,  imploring  sympathy  and  demanding  energetic  treat- 
ment. Fancied  stricture,  next  to  fancied  spermatorrhoea,  is  a  very 
common  hypochondriacal  expression  of  perverted  sexuality,  such  as  is 
found  among  those  who  heedlessly  allow  the  brain  to  stimulate  their 
erotic  fancies  and  sexual  needs,  without  being  able  to  set  Nature  at 
rest  by  satisfying  her  demands,  or  who,  on  the  other  hand,  abuse 
themselves  sexually  by  physical  as  well  as  intellectual  excess. 

These  patients  require  kind  and  gentle  management.  They  must 
be  put  right  about  the  cause  of  their  troubles,  and  their  sexual  hygiene 
must  be  regulated.  This  can  be  accomplished  only  by  marriage,  or  by 
purity  of  thought  and  absolute  continence. 

10 


146       TREATMENT  OF  STRICTURE  OF  THE  URETHRA. 


CHAPTER  YIIL 
TREATMENT  OF  STRICTURE  OF  THE  URETHRA. 

Witli  Details  for  all  Complications,  and  a  Rfcapitiilation. 

The  treatment  of  stricture  of  the  urethra,  and  of  its  results,  may 
be  considered  under  three  heads  : 

1.  Treatment  of  UncomjjUcated  Stricture — 

{a)  Of  Large  Caliber. 

(/;)  Of  Small  Caliber. 

(c)  Of  the  :Mcatus. 

(f?)  Traumatic. 

{e)   Resilient — often  irritable. 

2.  Treatment  of  Stricture  complicated  by— 

(a)  False  Passage. 

{b)  Retention. 

(c)  Retention — the  Stricture  being  impassable. 

{d)  Infiltration. 

(e)  Abscess. 

(/)  Fistula. 

(g)  Pericystitis. 

(h)  Enlarged  Prostate. 

3.  Treatment  of  Fistula  with  Loss  of  Substance. 

1,  Treatment  of  Uxcomplicated  Stricture. 

(«)  Of  Large  Caliber. — The  majority  of  strictures  which  the  sur- 
geon is  called  upon  to  treat  are  of  large  caliber.  The  symptom  of 
which  the  patient  complains  is  persistent  gleet,  following  gonorrhoea, 
or  bastard  gonorrhoea,  with,  possibl}^  some  frequency  in  urination. 
These  cases  are  of  daily  occurrence  and  often  pass  unrecognized,  the 
gleet  being  treated,  the  stricture  overlooked.  Too  much  stress  cannot 
be  laid  upon  the  importance  of  exploring  the  urethra,  in  such  cases 
of  gleet,  with  the  bulbous  bougie.  One,  two,  or  more  strictures  are 
found,  the  smallest,  which  is  jirobably  the  deepest,  allowing  passage, 
perhaps,  to  a  No.  15  bulb. 

Treatment  here  is  most  simple.  After  the  diagnosis  has  been  made, 
no  further  instrumentation  is  advisable  (if  the  patient  can  spare  the 
time),  until  the  effect  of  exploration  has  been  observed.  The  chances 
of  urethral  chill,  after  first  examinations,  must  be  remembered.  The 
patient's  general  condition  and  habits  must  be  studied,  and  his  urine 
tested  for  acidity  or  j^ossiblc  kidney  disease.     He  must  be  instructed 


UNCOMPLICATED   STRICTURE.  147 

in  urethral  hygiene,  and  the  nature  of  his  malady  explained  to  him, 
and  he  should  be  informed  at  the  outset,  to  forestall  future  disappoint- 
ment, that,  after  his  symptoms  have  been  removed  by  treatment,  the 
permanence  of  his  cure,  if  his  stricture  is  in  the  deep  urethra,  may  de- 
pend upon  the  use  of  an  instrument  upon  himself  at  proper  intervals, 
with  the  view  of  preventing  tendency  to  recontraction  of  his  stricture. 
Being  instructed  not  to  mind  the  smarting  at  his  next  urination, 
and  given  such  alkali,  balsam,  or  injection  as  the  acidity  of  his  urine 
and  amount  of  discharge  seem  to  call  for,  the  patient  is  dismissed,  to 
return  in  two  days,  to  have  his  treatment  commenced.  The  treatment 
which  generally  gives  satisfaction  in  a  majority  of  these  cases  is  dila- 
tation with  the  conical  steel  sound.  One  of  these  instruments  properly 
warmed  is  introduced  in  the  manner  already  detailed.  Its  size  should 
correspond  to  that  of  the  bulbous  bougie,  which  has  passed  tlie  strict- 
ure, and  the  utmost  delicacy,  care,  and  gentleness  should  be  used  in 
its  introduction.  The  wedge  and  lever  should  not  be  forgotten,  nor 
should  we  abuse  power  because  we  possess  it.  At  the  strictured  and 
tender  points  a  spasmodic  contraction  may  occur,  arresting  the  instru- 
ment. To  overcome  this,  patience  is  better  than  force.  As  soon  as 
the  instrument  has  entered  the  bladder  it  should  be  at  once  gently 
withdrawn.  Nothing  is  gained  by  leaving  it  even  for  a  moment. 
During  withdrawal  the  stricture  is  usually  felt  to  "grasp"  the  sound. 
This  "grasping"  is  the  result  of  muscular  spasm  provoked  by  the 
presence  of  the  instrument.  It  will  sometimes  relax  if  the  sound  be 
allowed  to  rest  a  moment.  After  one  sound  has  been  withdrawn,  a 
second  and  even  a  third  may  be  introduced,  if  it  is  considered  safe. 
No  rule,  nothing  short  of  personal  experience,  can  indicate  how  far 
the  dilatation  may  be  pushed  at  one  sitting.  The  tendency  is  alwavs 
to  hurry  and  to  use  force  ;  a  course  detrimental  to  rapid  progress.  It 
may  be  stated  as  a  rule,  subject  to  judicious  exception,  that  if  a  cojiical 
steel  instrument  of  any  size  larger  than  No.  15  tvill  not  enter  a  strict- 
ure iy  its  own  weight  after  a  little  delay,  luhen  held  in  proper  position, 
it  should  not  be  used.  Every  urethra,  however,  has  its  own  temper, 
as  it  were  ;  some  are  aroused  by  the  slightest  disturbance,  while  others 
will  bear  considerable  violence  without  protest.  A  surgeon  should  ac- 
quaint himself  withthe  temper  of  a  given  urethra  by  gradual  experi- 
ment, before  he  takes  liberties  with  it.  The  mischief  to  be  feared 
from  the  employment  of  large  sounds  with  force,  besides  false  passages, 
which  are  not  apt  to  be  produced  by  large  instruments,  is  threefold  : 

1.  The  production  of  epididymitis,  a  common  result  of  violence  to 
the  urethra,  and  a  complication  which  suspends  treatment  and  con- 
fines the  patient  for  several  days,  or,  it  may  be,  weeks. 

2.  The  excitement  of  inflammation  in  the  stricture,  which  aggra- 
vates its  condition  and  defeats  the  end  of  the  treatment  employed. 

3.  The  production  of  chill  and  urethral  fever. 


148        TREATMENT  OF  STRICTURE  OF  TUE  URETHRA. 

In  rare  instances  epididymitis  may  come  on  in  spite  of  care.  Tlie 
complication  mnst  be  properly  attended  to,  and  all  treatment  of  the 
urethra  suspended  until  the  jiain  in  the  testicle  has  nearly  subsided 
and  the  swelling  of  the  epididymis  has  assumed  an  indolent  character. 
It  is  not  necessary  to  wait  for  the  latter  to  disappear  entirely,  and,  if 
extra  care  be  employed  in  resuming  the  use  of  instruments,  there  is 
little  danger  of  })rovoking  relapse,  "While  using  instruments  in  the 
urethra,  especially  at  the  beginning  of  a  course  of  dilatation,  the  pa- 
tient should  be  advised  to  wear  a  suspensory  bandage  to  keep  the  tes- 
ticles from  exposure  to  injury,  which  would  render  them  more  liable 
to  epididymitis. 

At  each  subsecpient  visit  of  the  patient,  the  surgeon  commences 
with  a  sound  from  one  to  two  sizes  smaller  than  the  last  instrument 
introduced  at  the  previous  visit,  and  carries  the  dilatation  as  far  as 
possible  without  the  employment  of  force — this  till  the  full  size  is 
reached. 

The  most  irajiortant  feature  in  the  treatment  of  stricture  by  dilata- 
tion is,  a  proper  regulation  of  the  intervals  to  be  allowed  between  the 
sittings.  The  intervals  usually  recommended  are  too  short.  Occa- 
sionally we  see  patients  who  attempt  to  treat  themselves,  introducing 
a  bougie  into  the  urethra  daily,  or  twice  daily,  perhajjs  at  every  act  of 
urination,  aggravating  every  symptom,  worrying  the  urethra  and 
bladder  into  a  state  of  inflammation,  and  wondering  why  the  stricture 
does  not  get  well.  Some  surgeons,  unfortunately,  are  guilty  of  the 
same  error  in  a  less  degree.  To  solve  the  problem  of  the  proper  inter- 
val for  reintroducing  a  sound  through  a  stricture,  it  is  only  necessary 
to  study  the  effect  of  a  single  introduction. 

Suppose  a  stricture  which  sensibly  diminishes  the  size  of  the  stream 
of  urine,  and  is  attended  by  gleet.  Through  this  stricture  a  conical 
instrument  is  introduced,  which  is  arrested  for  a  moment,  but  gradu- 
ally passes,  stretching  the  stricture,  and  is  distinctly  "grasjied  "  as  it 
is  being  withdrawn.  What  follows  such  an  operation  ?  At  the  next 
act  of  urination  the  stream  is  larger,  and  continues  so  during  twenty- 
four  hours,  xit  the  end  of  this  time  the  stream  is  nearly  as  small 
as  it  was  before  the  sound  was  used  ;  the  gleet  is  the  same,  or  possi- 
bly increased.  Now,  for  twenty-four  to  forty-eight  hours  the  stream 
steadily  becomes  smaller,  while  the  discharge  grows  more  abundant 
and  creamy,  Duriug  the  third  or  fourth  day,  improvement  com- 
mences ;  the  stream  again  grows  larger,  the  discharge  becomes  thinner 
and  less  copious,  and  this  improvement  often  continues  through  the 
fifth  and  sixth  or  even  seventh  days,  or  longer — after  which  the  vol- 
ume of  the  stream  commences  to  diminish  and  the  discharge  to  be- 
come thicker. 

In  such  a  case,  if  the  same  conical  instrument  first  used  had  been 
reintroduced  at  the  end  of  twenty-four  hours,  it  would  have  passed 


PROPER  INTERVALS  FOR  INTRODUCING  SOUND.        I49 

the  stricture  witli  about  the  same  facility  as  on  the  day  before  ;  if 
after  forty-cigbt  hours,  it  would  enter  with  more  difficulty  ;  if  at  the 
end  of  seventy-two  hours,  it  would  again  enter  as  easily  as  on  the  first 
day ;  if  reintroduction  were  first  attempted  on  the  fourth  day,  the 
sound  would  pass  more  easily  than  at  first ;  if  on  the  fifth,  with  more 
ease  still,  and  it  would  not  probably  be  so  tightly  "grasped  "  on  with- 
drawal ;  while  in  some  cases  the  greatest  ease  of  reintroduction  is 
attained  on  the  sixth,  seventh^  eighth  day,  or  even  later.  This  varies 
in  different  cases  ;  but  it  may  be  stated,  as  a  rule,  that  it  is  had  sur- 
gery, in  treating  stricture  by  dilatation,  to  reintroduce  an  instrument 
— unless  it  he  filiform — hefore  the  lapse  of  at  least  seventy -two  hours, 
and  that  more  rapid  progress  will  he  made  with  the  case  hy  waiting 
till  after  ninety  six  hours — often  even  until  the  sixth,  seventh,  or 
eighth  day. 

The  reason  for  this  rule  becomes  clear  ujaon  studying  the  thera- 
peutic effect  of  pressure  upon  stricture-tissue.  The  first  effect  is 
mechanical  (stretching)  and  sedative  (quieting  muscular  spasm  at  the 
strictured  point)  ;  this  lasts  twenty-four  hours.  The  next  effect  is 
reactionary  (congestive  and  spasmodic),  resulting  in  extra  tightness  of 
the  stricture  and  increase  of  discharge  ;  this  lasts  from  twenty-four  to 
forty-eight  hours.  The  final  curative  effect  is  absorptive.  Absorption 
is  excited  by  the  increased  activity  of  the  circulation  about  the  strict- 
ure, and  continues  for  two  or  three  days,  or  longer  ;  after  which,  con- 
traction and  growth  of  stricture-tissue  recommence.  It  is  just  at  the 
period  where  absorption  ceases  and  recontraction  commences  that  a 
dilating  instrument  can  be  reapplied  most  effectively,  and  this  period 
is,  in  the  majority  of  cases,  on  the  fifth  to  the  eighth  day.  In  brief, 
intervals  of  a  iveeTc,  especially  in  cases  of  old  stricture,  are  generally 
more  heneficial  than  any  shorter  period. 

That  absorption  takes  place  during  the  cure  of  stricture  by  dilata- 
tion may  be  proved  during  life  by  examining  the  hard  cartilagiuous 
bands  often  found  surrounding  the  urethra,  and  constituting  stricture. 
These  bands  can  be  distinctly  felt,  over  an  instrument  introduced 
through  the  stricture,  and,  during  the  treatment,  they  may  be  observed 
to  become  gradually  smaller,  until  they  become  almost  imperceptible. 
They  rarely  disappear  entirely. 

As  to  the  degree  of  dilatation  which  is  to  be  aimed  at,  every  ure- 
thra has  its  own  gauge  in  the  size  of  its  meatus — provided  that  meatus 
be  not  congeni tally  small,  or  contracted  by  disease.  If  there  is  any 
cicatricial  tissue  in  the  circle  of  the  meatus,  or  if  a  probe  can  make  out 
any  pouching  below  the  lower  commissure  (Fig.  51),  the  meatus  is 
strictured,  and  requires  treatment. 

The  normal  meatus,  however,  is  the  smallest  part  of  the  healthy 
canal,  and  the  object  in  view  is,  to  bring  all  available  pressure  to  bear 
upon  a  morbid  narrowing  of  some  other  portion  of  the  tube.     To  do 


150  TREATMENT   OF  STRICTURE   OF  THE   URETHRA. 

this  the  meatus  must  be  put  lightly  upon  the  stretch.  "When  the 
meatus  is  stretched,  the  feeling  is  one  of  discomfort,  which  subsides 
after  the  instrument  has  been  in  place  for  a  moment.  If  the  meatus 
is  overstretched,  a  distinctly  marked,  narrow  white  line  will  be  seen 
encircling  the  instrument  upon  the  lips  of  the  urethral  orifice,  indi- 
cating that  tlie  latter  have  been  deprived  of  blood  by  pressure.  So 
much  distention  is  unbearable,  but  the  greatest  amount  short  of  this 
should  be  aimed  at. 

The  meatus  may  often  be  cut,  even  when  not  obviously  too  small,  in 
order  to  facilitate  the  use  of  a  sound  larger  than  would  otherwise  i)ass, 
for  the  greater  the  extent  to  which  dilatation  is  carried,  the  easier  will 
it  be  to  keep  the  deep  stricture  ojieu,  perhaps  even  to  cure  it  by  dila- 
tation. 

The  teachings  of  Dr.  Otis  in  this  direction  are  valuable,  altiiough 
I  believe  his  dictum  to  be  too  dogmatic  and  to  be  api)lied  by  him  too 
sweepingly.  He  establishes  a  fixed  limit  as  to  the  proper  size  which 
the  urethra  should  possess,  and  it  may  be  said  that  such  a  standard 
may  be  safely  reached  and  maintained  in  any  case.  The  question  of 
the  necessity  of  attaining  this  high  degree  of  dilatation  in  all  cases  is 
very  questionable.  Patients  can  often  be  cured  without  carrying  them 
up  to  the  Otis  limit,  but  in  some  cases  their  cure  is  more  easily  clfected 
and  more  permanent  if  they  are  brought  up  to  a  size  which  he  con- 
siders a  tyije  in  a  given  case. 

The  only  objection  to  Dr.  Otis's  high  standard  is  that  it  entails  an 
amount  of  cutting — often  in  my  opinion  (guided  by  a  reasonably  long 
and  unbiased  experience)  unnecessary — since  the  patient  can  get  well 
without  it,  and  because  extensive  cutting  of  the  anterior  urethra  leaves 
the  canal  defective  in  expulsive  power.  The  urine  dribbles  away  at 
the  end  of  the  act  of  urination  from  these  widely-cut  canals  more  than 
it  does  from  a  normal  urethra,  and  many  patients  complain  of  the  in- 
convenience so  caused.  Strictures  of  the  anterior  urethra,  if  very 
freely  cut,  may  be  radically  cured,  not  so  strictures  of  the  deep  ure- 
thra. The  latter  get  well  sometimes  under  all  varieties  of  treatment — 
in  most  instances  they  require  the  occasional  use  of  a  dilating  instru- 
ment for  an  indefinitely  long  period,  or  recontraction  occurs. 

If,  then,  the  surgeon  desires  to  enlarge  the  jiatient's  stricture  as 
widely  as  he  can  in  safety,  and  wishes  a  test  as  to  the  limit  in  size  of 
the  sound  which  he  shall  use,  I  know  of  no  better  ultimate  limit  than 
the  scale  proposed  by  Otis,  giving  it  as  my  personal  opinion  that, 
while  his  limit  may  be  safely  aspired  to  and  reached,  it  is  wiser  to  fall 
short  of  the  standard  by  a  few  sizes,  in  which  case  all  the  advantage 
claimed  by  Otis  will  be  ordinarily  secured,  and  some  of  the  disadvan- 
tages of  a  urethra  unnaturally  wide  will  be  av^oided. 

Dr.  Otis's  standard  is  practically  as  follows.*     He  bases  it  upon 

*  "  Genito-Urinary  Diseases  and  Syphilis,"  1883,  p.  441. 


OF  SMALL   CALIBER.  151 

extensive  experiments  by  measurement  with  his  urethrameter.  The 
size  to  which  a  urethra  may  be  brought  is  ascertained  by  measuring 
the  circumference  of  the  flaccid  penis  : 

Circumference  of  penis,  3  inches  ;  the  urethra  should  take  size  30. 

Circumference  of  penis,  3i  inches  ;  the  urethra  should  take  size  32. 

Circumference  of  penis,  3^  inches  ;  the  urethra  should  take  size  34. 

Circumference  of  penis,  3f  inches  ;  the  urethra  should  take  size  3G. 

Circumference  of  penis,  4  inches  ;  the  urethra  should  take  size  38. 

Circumference  of  penis,  4^  to  4^  inches  ;  the  urethra  should  take 
size  40. 

That  these  sizes  may  be  safely  attained,  the  long  experience  of  Dr. 
Otis  proves.  That  they  are  generally  necessary,  I  personally  am  not 
convinced.  That  they  may  sometimes  be  desirable,  I  believe.  The 
limit,  however,  I  consider  a  little  too  large  for  practical  adoption,  and 
I  prefer,  in  cases  that  will  get  well  without  reaching  so  large  a  size, 
to  disregard  it ;  in  others,  to  scale  down  a  few  sizes — believing  that  as 
much  good  may  be  so  attained,  and  some  possible  harm  and  often 
some  complaint  from  the  patient  averted. 

As  soon  as  a  full-sized  instrument  will  slip  through  a  stricture  by 
its  own  weight,  all  symptoms  will  usually  have  ceased,  unless  the  stric- 
ture be  very  resilient ;  but  recontraction  will  almost  inevitably  take 
place  in  stricture  of  the  deep  urethra,  unless  the  cure  be  maintained 
by  the  patient.  This  is  easily  done,  and  no  intelligent  patient  objects 
to  it.  He  acquires  the  art  of  gently  passing  a  sound  upon  himself  in 
a  few  lessons,  and  he  should  be  seriously  cautioned  to  perform  this 
trifling  but  important  oj)eration  at  first  weekly,  then  fortnightly,  then 
monthly,  studying  his  own  case  to  determine  how  long  an  interval  he 
can  allow  without  sensible  recontraction  of  his  stricture.  In  this  way, 
in  some  cases,  the  use  of  instruments  may  be  gradually  abandoned  ; 
in  the  majority,  it  will  have  to  be  continued  indefinitely,  at  intervals 
varying  from  a  week  to  several  months.  In  this  way  does  the  cure 
become  radical.  The  surgeon  is  responsible  for  the  cure  only  on  con- 
dition that  the  patient  carries  out  this  plan  ;  or,  rather,  the  patient  is 
responsible  for  the  permanence  of  his  own  cure,  and  this  he  must  be 
made  distinctly  to  understand. 

(b)  Stricture  of  Small  Caliber . — To  this  class  belong  strictures  ad- 
mitting any  instrument  less  than  No.  15.  They  are  arranged  under  a 
special  head,  not  because  they  require  different  treatment,  but  in  order 
to  emphasize  the  fact  that  by  far  the  greater  number  of  such  cases  are 
better  treated  with  soft  than  with  steel  instruments.  The  danger  of 
making  a  false  passage  in  an  obstructed  urethra  with  a  small  metallic 
instrument  can  not  be  overrated.  N'o  one  can  appreciate  the  ease  with 
which  a  false  passage  is  made  until  he  has  himself  made  one.  Indeed, 
it  is  not  very  uncommon  for  a  patient  or  surgeon,  not  well  acquainted 
with  the  urethra,  to  make  a  false  passage,  and  go  on  dilating  it  instead 


152  TREATMENT   OF   STRICTURE   OF   THE   URETHRA. 

of  the  stiicturc,  woudcring  meantime  that  tlie  size  of  the  stream  is  uot 
increased  or  the  symptoms  alleviated.  A  surgeon  who  knows  every 
line  of  the  urethra  may  occasionally  assume  the  risk  of  using  a  small 
metallic  instrument  in  the  canal  without  a  guide,  but  only  in  excep- 
tional cases.  Below  No.  15,  soft  instruments  only  should  be  employed, 
unless  there  be  a  guide  through  the  stricture. 

Dilatation  is  carried  on  as  already  directed,  steel  instruments  being 
used  as  soon  as  the  stricture  will  admit  15.  Progress  is  slower  with 
soft  than  with  steel  instruments ;  they  usually  give  the  patient  more 
pain  ;  the  intervals  between  their  introduction  may  be  somewhat 
shorter. 

Cutting  (internal  urethrotomy)  and  stretching  (divulsion)  opera- 
tions are  growing  daily  in  favor  in  the  treatment  of  strictures  of  small 
caliber ;  yet,  in  a  case  of  uncomplicated  stricture  in  the  deep  urethra, 
no  matter  how  tight  it  may  be,  if  it  is  not  resilient,  and  is  not  of  trau- 
matic origin,  if  any  instrument  at  all  can  be  passed,  dilatation  is  still 
the  best  method  of  treatment.  Scarification  and  divulsion  are  only 
helps.  They  are  attended  by  danger.  They  do  not  cure  radically. 
The  sound  must  be  used  after  them.  When  pursued  with  gentleness 
and  care,  the  patient  need  not  lose  a  day  from  business  on  account  of 
treatment  by  dilatation,  nor  be  confined  an  hour  to  the  house ;  while 
the  risk  of  exciting  complications  is  at  a  minimum.  The  treatment  is 
longer  surely,  but,  if  the  surgeon  will  imagine  what  would  be  his  own 
wish  were  he  in  the  patient's  situation,  he  will  not  hesitate  to  ado])t 
the  safer  but  more  tedious  method. 

For  the  class  of  strictures  (uncomplicated)  now  under  consideration, 
exception  may  be  made  in  favor  of  divulsion  or  internal  urethrotomy 
in  two  classes  of  cases  : 

1.  If  the  patient  can  not  give  enough  time  to  carry  out  dilatation 
properly. 

2.  If  pretty  severe  urethral  fever  follows  attempts  at  dilatation. 
All  the  foregoing  remarks  apply  to  strictures  at  and  deeper  than 

the  bulbo-membranous  junction.  In  the  light  of  modern  experience 
it  may  be  safely  stated  that  all  true  strictures  of  the  pendulous  urethra 
may  be  radically  cured  by  free  cutting  internally.  This  has  been 
clearly  demonstrated  by  Otis,  and  the  profession  is  indebted  to  him  for 
the  demonstration  and  for  showing  the  harmlessness  to  life  even  of 
his  extensiA'e  operations.' 

Radical  cures  are  accomplished  by  free  cutting  anteriorly — not  so 
in  the  deep  urethra.  Therefore  the  Otis  operation  is  a  good  one — per- 
haps not  quite  up  to  his  typical  limit — for  strictures  of  the  pendu- 
lous urethra.  This  remark  applies,  however,  in  my  opinion,  only  to 
true  strictures,  not  to  the  moderate  narro wings  which  I  have  described 
as  physiological  points  of  narrowing,  even  although  these  points  be 
covered  by  granulations,  and  yield  a  gleet.    Such  gleets  may  usually  be 


OF   SMALL   CALIBER.  153 

cured  without  cutting.  Sometimes  they  can  not  be  cured  even  by  ex- 
tensive interniil  urethrotomy. 

In  commencing  the  treatment  it  may  be  impossible  to  enter  the 
bladder  with  any  instrument,  either  on  account  of  the  tightness  of  the 
stricture,  or  because  the  point  of  the  instrument  does  not  engage  in 
the  latter,  or  is  arrested  by  some  fold  or  lacuna  beyond.  In  these 
cases  gentle  perseverance  and  skill  will  rarely  fail  of  success.  The  dif- 
ferent varieties  of  filiform  bougies,  witli  the  different  mana3uvres  and 
expedients  of  introduction  already  detailed,  will  rarely  fail  to  triumph 
over  all  difficulties.  Sooner  or  later  the  bladder  is  reached,*  and  the 
case  is  under  control.  On  the  third  or  fourth  day  the  same  filiform 
instrument  will  pass  with  greater  facility,  and  a  larger  one  will  usually 
follow  :  the  treatment  by  dilatation  is  fairly  under  way. 

In  those  exceptional  cases  Just  alluded  to,  where  a  filiform  bougie 
only  can  be  introduced  after  long  and  persevering  effort,  it  becomes  a 
serious  question  whether  it  is  not  better  to  utilize  the  guide  thus  intro- 
duced through  the  stricture,  to  conduct  another  instrument  upon  it, 
rather  than  to  run  the  risk  of  retention  from  swelling  of  the  stricture 
after  the  guide  has  been  removed,  and  perhaps  incur  the  necessity 
of  operating  under  less  favorable  circumstances.  The  temptation  to 
operate  in  these  cases  is  great,  but  the  necessity  for  it  is  often  more 
apparent  than  real.  True,  if  the  stricture  be  very  tight,  retention  may 
result  from  disturbing  it,  especially  if  the  urine  be  acid,  but  this  reten- 
tion yields  to  heat  and  opium,  or  the  same  filiform  instrument  which 
caused  the  trouble  may  usually  be  reintroduced ;  finally,  the  asjDirator 
might  be  used  :  in  any  case,  after  seventy-two  hours,  a  larger  instru- 
ment will  rarely  fail  to  pass,  and  dilatation  has  commenced  to  effect  a 
cure.  Hence,  in  many  of  these  cases,  where  the  patient  can  afford  the 
time,  dilatation  is  the  preferable,  because  the  safer,  treatment. 

In  the  so-called  impassable  stricture  (uncomplicated),  where  urine 
passes  out,  but  no  instrument  can  be  made  to  enter  the  bladder,  a  fili- 
form bougie  can  invariably,  with  patience,  be  inserted  into  the  orifice 
of  the  stricture.  That  it  has  entered  is  known  by  the  ''grasping''  of 
the  instrument  by  the  stricture.  If  now  the  bougie  be  left  engaged 
during  eight  or  ten  minutes,  the  muscular  spasm  constituting  the 
"grasp"  may  yield  and  allow  it  to  advance  ;  if  not,  another  attempt 
may  be  made  in  twenty-four  or  forty-eight  hours,  when,  if  it  will  not 
pass,  it  will  at  least  enter  the  stricture  to  a  greater  depth  ;  finally,  skill 
will  overcome  it  and  the  surgeon  advances  to  higher  numbers.  Model 
bougies  are  useless.     Whalebones  are  superior  to  all  other  means. 

In  any  of  the  above  cases,  if,  after  sufficient  deliberation,  it  is  de- 

*  In  one  (personal)  case  it  required  ten  sittings,  most  of  them  over  one  hour  long,  be- 
fore any  instrument  could  be  made  to  enter  the  bladder.  On  the  tenth  effort,  the  instru- 
ment passed.  It  entered  the  bladder,  and  at  once  the  stricture  was  divulsed.  In  tv.o 
weeks  the  patient  passed  his  own  full-sized  instrument. — Ketes. 


154  TREATMEXT   OF   STRICTURE   OF   THE   URETHRA. 

cided  to  onlar^fc  the  stricture  before  withdrawinii:  the  guide,  a  choice 
of  operations  must  bo  made.  If  it  is  only  intended  to  enlarge  the 
stricture  sutHciently  to  make  its  entrance  by  a  dilating  instrument 
more  easy-after  a  few  days,  if  tiie  guide  be  a  soft  filiform  bougie  fur- 
nished with  a  screw,  a  larger  bougie  or  silver  catheter  may  be  screwed 
into  it,  and  the  compound  instrument  carried  into  the  bladder ;  or,  if 
the  guide,  as  is  usually  the  case,  be  a  whalebone  bougie,  a  tunneled 
sound  may  be  slipped  over  it  and  gently  but  firmly  carried  through 
the  stricture,  a  little  force  being  used,  but  at  the  same  time  great 
care  takeu  not  to  bend  the  guide  in  front  of  the  advancing  instru- 
ment. 

If  it  is  iuteuded  to  relieve  the  stricture  at  once,  the  broad  rule  is — 
all  strictures  of  the  pendulous  urethra,  if  operated  upon,  should  he  cut ; 
all  strictures  of  the  fixed  urethral  curve  should  he  treated  by  external 
section  or  combined  internal  and  external  urethrotomy.  Bleeding 
from  the  pendulous  urethra  can  always  be  controlled  by  direct  press- 
ure ;  not  so  easily  that  from  the  bulb  or  membranous  urethra.  The 
operative  procedures  have  been  detailed  (Chapter  VI). 

If  a  stricture  of  the  pendulous  urethra  is  so  small  as  to  require  im- 
mediate radical  measures,  it  should  first  be  stretched  by  Thompson's 
divulsor  on  a  guide,  until  it  will  admit  Oiviale's  or  Otis's  urethrotome. 
When  stricture  of  the  deep  urethra  is  too  tight  to  justify  ordinary 
treatment  by  dilatation,  and  when  cutting  is  not  practicable  for  any 
reason,  it  may  be  divulsed,  or  moderately  cut  with  a  Maisonneuve  ure- 
throtome, or  moderately  stretched  with  Thompson's  dilator  or  with 
tunneled  sounds  up  to  the  point  where  ordinary  treatment  by  dilata- 
tion becomes  possible.     The  latter  expedients  I  consider  preferable. 

(c)  Stricture  of  the  Meatus. — Stricture  at  or  very  near  the  meatus 
is  usually  made  worse  by  attempts  at  dilatation  bej'ond  a  certain  limit, 
after  which  it  becomes  irritated,  inflamed,  and  refuses  to  dilate.  To 
a  still  greater  degree  is  this  true  of  congenital  or  cicatricial  narrowing 
of  the  meatus.  In  all  these  cases,  the  contraction  must  be  cut,  pref- 
erably with  a  straight  or  with  any  instrument,  toward  the  tioor  of 
the  urethra  up  to  or  through  the  fraenum.  The  orifice  should  be  cut 
a  little  larger  than  it  is  estimated  to  have  been  the  original  intention 
of  Nature  to  make  it,  since  slight  contraction  necessarily  takes  place 
in  healing.  Ha?morrhage,  in  this  operation,  is  considerable,  if  the 
corpus  spongiosum  be  cut  into.  It  may  always  be  arrested  with  a  strip 
of  rubber  plaster. 

Reflex  irritation  may  produce  spasmodic  stricture  in  these  cases,  so 
that  the  next  attempt  to  urinate  is  perhaps  inefl'ectual.  Removing 
the  plaster,  dipping  the  penis  in  warm  water,  and  reassuring  the 
patient,  will  invariably  bring  a  flow  of  urine.  A  meatus,  properly  cut, 
remains  open  indefinitely,  without  the  necessity  of  dilatation. 

{d)  Traumatic  Strictures  are  not  usually  amenable  to  treatment 


COMPLICATED   BY   FALSE   PASSAGE. 


155 


by  dilatation.  Thoy  are  so  exceptionally  ton;Lrli,  hard,  and  retractile, 
that  a  splice  or  splices  must  be  put  into  them,  by  rupture  or  section, 
in  order  to  keep  them  open.  Since  the  days  of  Syme,  it  has  been  cus- 
tomary to  consider  perineal  section  indicated  wherever  stricture  of 
the  membranous  urethra  was  of  traumatic  origin.  This  rule  still 
holds  good,  for,  although  these  strictures  may  in  exceptional  instances 
be  overcome  by  divulsion  or  by  internal  urethrotomy,  yet  the  risk  of 
perineal  section  is  not  greater,  and  the  after  effect  is  more  perfect  and 
more  easily  maintained  permanent. 

(e)  Resilient  Stricture. — Strictures  which  are  thoroughly  resilient 
will  not  dilate.  In  such  cases,  if  a  given  instrument  be  introduced, 
the  stream  becomes  smaller  at  once,  and  on  the  fourth  day  the  same 
instrument  enters  with  more  difficulty,  or  perhaps  will  not  pass  at  all. 
These  strictures  are  frequently  irritable  as  well  as  resilient,  and  always 
call  for  internal  urethrotomy  in  the  pendulous  urethra,  combined 
internal  and  external  urethrotomy,  or  perineal  section  in  the  deep 
urethra. 

2.    TkEATMEISTT    of   StEICTURE    COMPLICATED   BY — 

{a)  False  Passage. — False  i^assage,  as  already  stated,  results  from 
rough  or  unskillful  use  of  small  instruments  in  an  obstructed  urethra. 
It  may  be  due  to 


"  forced  catheter- 
ism,"  a  barbarous 
procedure,  con- 
demned by  its 
name  alone,  which 
consists  in  passing 
a  metallic  cathe- 
ter up  to  the  ob- 
stacle, and  then 
forcing  it  along 
in  the  supposed 
course  of  the  ure- 
thra, until  urine 
flows  through  it, 
if  haply  this  occur 
at  all.  It  is  not 
used  at  the  pres- 
ent date.  False 
passages  start  from 
the  bottom  of  la- 
cunae or  from  the 
front  face  of  a 
stricture,  from  in 
abscess  (Fig.  53). 


Pig.  53  {Dittel). 

front  of    the  triangular  ligament  or  from  some 
When  a  surgeon  makes  a  false  passage,  he  may  be 


156  TREATMEXT   OF   STRICTURE   OF   THE   URETHRA. 

unconscious  of  the  escape  of  the  point  of  liis  instrniuont  from  the 
canal,  but  he  will  soon  perceive  that  it  is  behaving  unusually.  It  does 
not  glide  along  as  if  in  a  healthy  urethra  ;  it  is  obstructed,  but  yet 
not  held  in  the  same  manner  as  if  in  the  grasp  of  a  stritture.  The 
point,  moreover,  seems  often  to  be  turned  out  of  the  median  line,  and, 
after  the  instrument  has  been  introduced  far  enough  to  have  reached 
the  bladder,  a  rotary  motion,  imparted  to  the  shaft,  will  show  that 
the  point  is  fixed  in  the  connective  tissue,  and  not  freely  movable, 
as  it  would  be  in  the  cavity  of  the  bladder.  In  such  a  case  a  linger 
in  the  perimeum,  or,  better  still,  in  the  rectum,  will  almost  certainly 
feel  the  point  of  the  instrument  just  outside  of  the  wall  of  the  gut, 
at  the  apex  of  the  prostate,  or  perhaps  lying  between  the  prostate  and 
the  gut.  On  withdrawing  the  instrument,  blood  flows  freely  from 
the  meatus. 

The  treatment  for  a  fresh  false  passage  of  this  sort  is,  to  let  it  alone 
absolutely  for  two  weeks,  if  the  patient  can  make  water,  and  is  in  no 
pressing  need  to  have  his  stricture  relieved.  Blood  will  flow  for  a  day 
or  two,  then  pus  for  a  few  days,  and  at  the  end  of  two  weeks,  in  fa- 
vorable cases,  the  passage  opened  by  the  instrument  will  have  closed. 
Occasionally  it  remains  open,  supjiurating  for  a  much  longer  time. 
ITrethral  fever,  with  or  without  the  formation  of  abscess,  is  not  an  un- 
common result  of  false  j^assage.  Infiltration  of  urine  is  exceedingly 
rare.  The  great  danger  in  these  cases  is  in  recommencing  instrumen- 
tation too  soon,  entering  the  false  passage  before  it  has  healed,  and 
thus  keeping  it  open  indefinitely. 

In  avoiding  an  old  false  passage,  wiiich  is  the  seat  of  chronic  sup- 
puration, its  position  must  be  accurately  studied  out,  by  observing  at 
what  point  in  the  urethra  an  instrument  engages  in  it,  and  from  which 
wall  of  the  canal  (upper  or  lower)  it  starts.  The  orifice  of  a  false  pas- 
sage once  accurately  located,  may  be  subsequently  avoided  by  making 
an  effort  to  present  the  beak  of  the  instrument  at  a  different  portion  of 
the  canal,  when  passing  the  dangerous  point.  A  new  false  passage 
does  not  grasp  an  instrument  like  a  stricture,  and  in  this  way  can  often 
be  distinguished  from  the  latter.  An  old  false  passage,  however,  so 
far  as  its  pathology  is  concerned,  is  a  traumatic  stricture.  It  has  hard 
walls,  and  the  unstriped  mascle  of  the  erectile  tissue  around  it  will 
"grasp"  like  any  other  stricture,  thus  depriving  the  surgeon  of  a  very 
valuable  means  of  deciding  whether  he  is  in  the  strictured  canal  of  the 
urethra  or  not. 

Another  means,  already  alluded  to,  of  avoiding  a  false  passage  when 
searching  for  the  orifice  of  a  narrow  stricture,  consists  in  filling  the 
urethra  with  whalebone  filiform  bougies,  thus  mechanically  filling  up 
the  false  passage,  until  some  instrument  will  glide  by  its  orifice  and 
enter  that  of  the  stricture.  This  course,  or  that  of  using  a  spiral- 
pointed  whalebone  bougie,  with  its  point  out  of  line  (Fig.  20),  should 


COMPLICATED   BY   RETENTION.  J  57 

be  employed  in  entering  the  stricture,  whenever  the  symptoms  are 
urgent,  and  false  passage  exists. 

If  a  guide  passes  the  stricture,  the  latter  may  be  stretched  with  a 
tunneled  instrument,  or  cut.  Tlie  size  of  the  beak  of  the  full-sized 
instrument,  subsequently  j)asscd,  will  insure  it  from  entering  the  false 
passage. 

If  it  is  impossible  to  get  through  the  stricture,  and  there  is  reten- 
tion, it  becomes  a  matter  of  personal  judgment  to  decide  whether  to 
perform  external  perineal  urethrotomy  without  a  guide,  or  to  use  the 
aspirator,  and  endeavor  to  pass  the  stricture  at  another  sitting. 

(b)  Retention. — A  patient,  with  stricture,  may  be  enjoying  good 
health,  when  suddenly,  after  exposure  to  cold,  after  a  dinner  or  a  ca- 
rouse, or  after  the  passage  of  a  small  instrument  through  his  stricture, 
he  finds  that  he  can  not  pass  water.  If  he  does  not  get  relief,  his  blad- 
der will  fill  up,  and  after  twenty-four  to  thirty-six  hours,  most  of 
which  are  passed  in  acute  suffering,  a  little  urine  will  force  its  way 
through  the  stricture,  and  he  will  have  overflow,  often  inaccurately 
styled  incontinence.  Such  an  overdistention  of  the  bladder  is  liable 
to  give  rise  to  atony  and  cystitis,  and,  if  the  patient  is  seen  before  it 
has  occurred,  every  means  should  be  employed  to  avert  it,  and  to  pre- 
serve the  bladder  from  an  injury  the  effects  of  which  are  sometimes 
permanent.  The  most  frequent  cause  of  retention  in  stricture  cases 
is  sudden  acute  inflammation  of  the  membrane  lining  the  stricture,  by 
which  the  already  narrow  canal  becomes  occluded.  In  this  condition, 
as  a  rule,  a  fine  catheter,  or  filiform  bougie,  can  be  introduced  through 
the  stricture,  by  the  exercise  of  patient  gentleness  and  skill.  If  the 
bladder  can  be  reached,  a  flow  of  urine  will  follow  the  withdrawal  of 
the  instrument.  If  the  bladder  can  not  be  reached,  the  patient  should 
be  placed  in  a  hot  bath,  more  hot  water  being  added  after  he  has  be- 
come accustomed  to  the  first  heat,  and  this  carried  as  high  as  is  bear- 
able. He  should  remain  in  the  bath  from  fifteen  to  twenty  minutes, 
and  will  often  be  able  to  empty  his  bladder  while  in  the  water. 
Another  excellent  expedient  is  the  use  of  the  sitz-bath,  at  a  tempera- 
ture of  100°  to  104°Fahr.,  more  hot  water  being  added  after  the  pa- 
tient has  entered  the  bath,  which  should  be  continued  only  for  about 
three  minutes,  and  may  be  repeated  after  an  interval  of  fifteen  min- 
utes. If  the  heat  is  sufficient  to  induce  nausea  or  faintness,  it  is  more 
likely  to  produce  the  desired  efi'ect  of  relaxing  the  stricture.*  A  piece 
of  ice  in  the  rectum  every  few  minutes  may  be  tried  (Cazenave). 

Failing  in  these  expedients,  if  percussion  reveals  a  bladder  only 
slightly  distended,  reaching  not  more  than  half  way  up  to  the  umbili- 
cus, opium  may  be  given,  one  grain  being  administered  every  hour 
until  relief  is  afforded.     The  nervous  excitability  attending  retention 

*  In  a  robust  and  full-blooded  subject,  it  might,  perhaps,  be  advisable  to  take  blood 
from  the  perineum  by  a  number  of  leeches. 


15S  TREATMEXT   OF  STRICTURE   OF  THE   URETURA. 

is  relieved  by  opium.  The  pain  will  soon  cease,  the  patient's  fears 
will  become  quieted,  and  after  the  fourth  or  fifth  grain  urine  will  gen- 
erally flow.  Twenty-drop  doses  of  the  sesquiciiloride  of  iron,  admin- 
istered every  fifteen  minutes,  for  a  couple  of  hours,  at  the  same  time 
with  the  ojiium,  seem  to  facilitate  relaxation  of  the  stricture.  Finally, 
an  instrument  can  often  be  introduced  under  the  entire  relaxation  of 
anaesthesia. 

In  a  case  of  retention,  if  a  fdiform  bougie  can  be  passed  into  the 
bladder,  the  advantage  so  gained  should  not  be  lost,  but  the  stricture 
should  be  divulsed  at  once,  if  the  history  of  the  case  show  an  advanced 
stricture,  and  there  are  no  evidences  of  kidney  disease.  If  no  instru- 
ment can  be  jxassed,  we  have  impassable  stricture,  with  retention, 
which  requires  other  means  for  its  relief.  In  drawing  off  the  urine 
from  a  bladder  suffering  from  overflow,  it  is  wise  never  to  empty  the 
viscus  entirely,  at  first,  if  it  has  been  long  overdistended.  Fatal 
collapse  has  been  caused  by  such  a  course,  and  subsequent  inflamma- 
tion of  the  overstretched  mucous  membrane  is  more  likely  to  run 
high  if  all  the  tension  be  taken  from  it  at  once.  Half  or  three  quar- 
ters may  be  withdrawn,  the  bladder  being  emptied  entirely  on  the  fol- 
lowing day.  This  fear  of  collapse  from  emptying  an  overdistended 
bladder  mainly  applies,  however,  to  old  subjects  suffering  from  en- 
larged prostate  and  stagnation  of  urine.  I  have  not  encountered  it  in 
cases  of  stricture. 

(c)  Retention,  the  Stricture  ieimj  impassahle. — No  stricture  (con- 
genital atresia  excepted)  is  impervious  unless  the  urethra  has  been  cut 
across  and  united  anteriorly,  all  the  urine  escaping  behind  it,  or  unless 
stricture  has  gone  on  contracting  for  an  indefinite  period,  the  urine 
escaping  through  large  fistulae.  Where  a  drop  of  urine  can  pass,  the 
stricture  is  pervious,  but  nevertheless  it  may  be  impassable  to  any  in- 
struments we  may  use,  or  any  skill  and  patience  we  may  bring  to  bear 
upon  it,  and  that,  too,  where  the  urine  flows  in  a  considerable  stream. 
Treatment  of  impassable  stricture  without  retention  has  been  already 
described. 

When,  however,  there  is  retention,  the  question  immediately  arises. 
Is  it  better  to  operate  on  the  stricture  at  once,  or  to  puncture  the 
bladder  and  wait  till  the  following  day,  in  hope  of  operating  then 
under  the  more  favorable  conditions  of  a  guide  through  the  stricture  ? 
This  is  a  point  which  requires  the  best  judgment,  aided  by  considera- 
ble experience,  to  decide  correctly.  Here  there  is  no  question  of  any 
other  complication.  The  surgeon  is  in  face  of  an  impassable  stricture, 
and  the  patient  has  retention,  and  must  be  relieved,  or  his  bladder 
will  suffer.  If  the  patient  has  had  retention  before,  his  experience 
then  will  aid  in  forming  a  judgment.  If  the  surgeon  is  acquainted 
with  the  temper  of  the  urethra  and  the  character  of  the  stricture  (re- 
siliency, traumatic  origin),  he  may  found  his  opinion  on  such  previous 


COMPLICATED   BY   EXTRAVASATION.  159 

knowledge.  If  the  pati'ent  is  difficult  to  manage,  and  there  is  fear 
that,  once  relieved  from  his  present  necessity,  he  may  not  submit  to 
treatment,  it  would  be  only  a  kindness  to  him  to  take  advantage  of 
his  misfortune  to  insist  upon  perineal  section  at  once,  and  put  him 
in  the  way  of  passing  a  large  instrument  and  keeping  off  further 
trouble,  thus  relieving  retention  and  subjecting  the  strictui-e  to  effect- 
ive treatment  by  one  operation. 

But  external  perineal  urethrotomy  without  a  guide  is  an  exceed- 
ingly difficult  operation,  and  is  not  to  be  undertaken  unadvisedly. 
If  it  is  the  patient's  first  retention  (brought  on  by  exposure),  and  if 
he  was  previously  passing  a  moderately  good-sized  stream,  if  the  blad- 
der is  not  already  too  full,  it  is  always  well  to  try  warm  baths  and 
opiates  to  relieve  retention  and  to  leave  the  stricture  for  subsequent 
treatment.  Again,  if  the  bladder  is  very  full,  and  there  is  still  no 
absolute  necessity  for  external  perineal  urethrotomy,  the  bladder 
should  be  punctured  above  the  pubis  with  the  asj)irator,  and  a  filiform 
bougie  engaged  if  possible  in  the  orifice  of  the  stricture,  and  left  to 
act  by  continuous  dilatation  (p.  164).  On  the  following  or  next  fol- 
lowing day  the  filiform  bougie  will  generally  pass  into  the  bladder,  and 
then  the  stricture  will  be  under  control. 

(d)  Infiltration  of  Urine. — In  stricture  complicated  by  extensive 
infiltration  of  urine,  we  have  a  condition  requiring  prompt  action  on 
the  part  of  the  surgeon.  The  stricture  must  be  relieved.  The  infil- 
trated urine  must  be  drained  off,  or  extensive  abscesses,  with  slough- 
ing, will  follow,  and  the  patient's  life  be  placed  in  imminent  peril — 
results  which  may  ensue  in  spite  of  all  precautions.  When  the  infil- 
tration has  occurred  behind  the  triangular  ligament  and  is  confined  to 
the  cavity  of  the  pelvis,  but  little  can  usually  be  done,  except  to  keep 
up  the  strength  by  brandy,  carbonate  of  ammonia,  and  beef-tea,  trust- 
ing that  Nature  will  set  up  a  plastic  inflammation  and  thus  limit  the 
burrowing  of  the  infiltrated  fluid,  and  allow  its  escaj)e  by  the  forma- 
tion of  abscess  (pericystitis).  Even  in  these  cases,  however,  desper- 
ate as  they  are,  where  the  escape  of  urine  has  been  sudden  and  in 
considerable  quantity,  early  operation  is  often  the  only  chance.  They 
are  similar  to,  and  must  be  treated  like,  cases  of  rupture  of  the  blad- 
der, the  neck  of  the  bladder  being  cut  into,  as  in  the  lateral  operation 
for  stone,  all  stricture-tissue  being  divided  and  a  chance  given  for  the 
infiltrated  urine  to  escape,  while  further  damage  from  infiltration  is 
rendered  impossible.  In  some  cases  it  is  better  to  tie  in  a  large  red 
rubber  tube  through  the  perineal  incision,  rather  than  to  cut  into  the 
vesical  neck. 

If  infiltration  occurs  along  the  course  of  the  urethra  outside  of  the 
triangular  ligament,  and  is  slight  and  circumscribed,  the  urine  not 
having  penetrated  Buck's  fascia,  but  manifesting  itself  in  a  hard,  cir- 
cumscribed perineal  swelling  (p.  138)  behind  the  stricture,  no  surgical 


160  TREATMENT   OF   STRICTURE   OF   THE   URETHRA. 

interference  is  called  for,  so  long-  as  the  hard  lunip  is  not  rapidly  in- 
creasing and  the  patient  can  empty  his  bladder.  Shonld  retention 
occur  nnder  these  circunistanees.  or  the  hard  luni])  commence  to  en- 
large rapidly,  external  perineal  urethrotomy  is  the  only  proper  re- 
source. In  this  variety  of  infiltration  there  is  often  time  to  build  uj> 
the  patient's  general  condition  by  the  judicious  employment  of  h3'gi- 
ene,  air,  tonics,  etc.,  and  sometimes  to  avert  the  consetjuences  of  long- 
continued  abuse  of  stimulants,  including  delirium  tremens,  often 
imminent  in  cases  encountered  in  hospital  practice.  Should  external 
perineal  urethrotomy  be  performed,  the  hard  lump  must  be  incised  in 
the  median  line,  and  the  stricture  thoroughly  divided. 

But  these  indurations  do  not  necessarily  sup]nn'ate  externally. 
They  usually  remain  stationary  for  a  long  time,  often  get  better  under 
treatment,  sometimes  (rarely)  spontaneously  subside,  ])robably  by  dis- 
charging internally  through  a  small  oriticc.* 

When  a  large  quantity  of  urine  has  suddenly  escaped,  burrowing 
into  the  subcutaneous  tissue  of  the  perinasum,  scrotum,  penis,  and 
abdomen,  large,  free  incisions,  calculated  to  insure  effective  drainage, 
should  be  made  well  down  into  the  subcutaneous  tissue,  wherever 
oedema  or  emphysema  is  felt,  and  external  perineal  urethrotomy  must 
be  performed.  A  thorough  division  of  the  stricture  ])revents  further 
infiltration.  If  the  scrotum  be  infiltrated,  it  should  be  split  into  two 
lateral  halves,  while  other  incisions  may  be  made  freely  into  its  sub- 
stance. Too  free  incisions  are  not  to  be  feared  ;  the  error  is  on  the 
other  side.  Incisions  must  be  bold,  deep,  numerous,  and  should  ex- 
tend over  all  the  surfaces  involved  by  infiltration.  The  operative  in- 
dications, in  cases  of  extensive  infiltration,  are  three  : 

1.  To  stop  progressive  infiltration  by  extensive  dependent  in- 
cisions. 

2.  To  provide  an  escape  for  urine  constantly  collecting  in  the  blad- 
der, by  free  central  incision  of  the  urethra  behind  the  stricture. 

3.  To  divide  the  stricture  thoroughly,  although  this  may  be  left 
for  a  subsequent  operation. 

In  making  incisions,  a  finger  in  the  rectum  should  search  for  boggy 
spots,  which,  when  found,  should  be  opened  into.  Brandy  and  car- 
bonate of  ammonia,  freely  administered  in  small,  frequent  doses,  will 
bring  down  the  pulse  as  the  patient  rallies  from  shock.  The  subse- 
quent treatment  must  be  sustaining  in  every  way. 

Gangrenous  spots  appearing  after  incision  should  be  poulticed  with 
charcoal  or  yeast  and  linseed-meal  until  they  separate,  and  the  raw 

*  Dr.  E.  A.  Banks,  of  New  Yorlc,  broufiht  a  patient  for  inspection,  wlio  with  tight 
stricture  had  two  of  tliese  deep  perineal  indurations,  one  as  larcc  as  a  pigeon's  egg,  evi- 
dently firmly  attached  to  the  urethra.  Before  agreeing  to  external  section,  which  was 
advised,  Dr.  Banks  tiied  " continuous  dilatation,"  with  the  effect  of  overcoming  the  strict- 
ure, and  causing  the  disappearance  of  the  indurations  after  a  few  weeks.  The  treatment, 
however,  provoked  epididymitis,  and  caused  some  urethral  irritation. 


COMPLICATED   BY  FISTULA.  1C,1 

surfaces  afterward  dressed  with  simple  stimulating  applications  until 
they  heal.  Recoveries  after  infiltration  seem  sometimes  almost  miracu- 
lous, and  life  is  not  to  be  despaired  of  eyen  in  cases  of  the  most  exten- 
sive sloughing.  Too  much  attention  can  not  be  bestowed  upon  keep- 
ing up  the  patient's  strength.  This  is  his  salvation  ;  it  must  be 
maintained  at  all  hazards. 

(e)  Abscess,  complicating  stricture,  has  already  been  described  as 
perineal  abscess,  and  as  a  hard,  circumscribed  swelling  along  the  course 
of  the  urethra  and  attached  to  it.  For  all  these,  when  complicating 
stricture,  the  treatment  which  usually  yields  the  Vjest  results  is  exter- 
nal perineal  urethrotomy,  including  the  abscess  and  the  stricture  in 
one  free  median  incision.  The  opening  should  be  made  before  fluctua- 
tion can  be  detected,  at  any  time  if  the  bladder  is  suffering.  Success 
of  treatment  usually  depends  upon  the  earliness  and  freedom  of  the 
incision  :  cut  deeply  in  the  inedian  line.  There  is  nothing  to  fear. 
Haemorrhage  can  always  be  restrained  by  tying  spurting  points  or 
plugging  the  wound  if  necessary  around  a  "shirted  cannula."  In  the 
anterior  urethra  abscess  should  not  be  opened  until  fluctuation  can  be 
felt.  Then  the  urethra  should  not  be  opened.  In  exceptional  cases 
it  may  be  laid  cleanly  open  by  a  longitudinal  incision  in  the  median 
line,  and  final  closure,  without  fistula,  may  be  hoped  for  in  most 
cases. 

{f)  FistulcB,  as  complicating  stricture,  are  important  just  in  pro- 
portion as  they  are  large,  long,  or  numerous.  A  simple  fistula  with 
one  or  two  openings,  which  allows  a  few  drops  of  urine  to  escape  at 
eacli  act  of  micturition,  need  not  be  regarded.  Such  a  fistula  will 
close  spontaneously,  in  the  vast  majority  of  instances,  as  soon  as  the 
stricture  has  been  dilated  fully,  as  Brodie  pointed  out.  The  first  and 
essential  step  in  the  treatment  of  all  fistulge  complicating  stricture  is, 
to  remove  obstruction  to  the  free  escape  of  urine,  and  then  to  treat  the 
fistulse,  if  they  do  not  get  well  spontaneously.  Such  after-treatment 
will  rarely,  be  required  unless  there  has  been  loss  of  substance.  If, 
however,  after  full  dilatation  has  been  maintained  for  some  months,  the 
fistulse  still  allow  urine  to  pass  during  micturition,  the  follo'U'ing  ex- 
pedients may  be  resorted  to  : 

Dilatation  being  maintained,  the  patient  should  be  further  taught 
the  use  of  a  rubber  or  a  flexible  olivary  catheter  of  medium  size.  This 
he  must  introduce  at  intervals,  passing  no  urine  except  through  the 
catheter,  if  it  can  be  done  without  producing  urethritis.  If  this  fail, 
after  thorough  trial  for  a  month  or  more,  where  the  stricture  has  been 
fully  dilated  and  is  not  resilient,  the  hard  edges  of  the  fistulous  tract 
should  be  incised  and  cleaned,  and  the  fistula  left  with  its  external 
larger  than  its  internal  orifice.  If  the  edges  are  hot  callous,  and  par- 
ticularly if  the  fistula  is  long  and  deep,  cauterization  is  sometimes 
effective.     This  is  best  accomplished  by  galvano-cautery,  a  wire  being 


X02        TREATMENT  OF  STRICTURE  OF  THE  URETHRA. 

introduced,  suddenly  raised  to  white  heat,  and  instantly  withdrawn. 
Ked-hut  iron  is  not  reliable,  as  it  becomes  cooled  on  introduction,  and 
produces  least  eifect  where  most  is  required,  i.  e.,  at  the  internal  ori- 
fice of  the -fistula.  Another  expedient  is  to  bend  a  silver  probe  until 
it  readily  traverses  the  whole  length  of  the  fistula,  coat  it  with  fused 
nitrate  of  silver,  introdnce  it  rajiidly,  and  rotate  it  duriiis:^  withdrawal. 

It  mast  not  be  forgotten  that  these  means  last  detailed  arc  only 
accessory  to  the  sound,  and  by  no  means  in  themselves  reliable  for 
cure.  During  their  use  the  catheter  and  full-sized  sound  should  be 
continued  unremittingly.  In  general,  the  capacity  of  the  uretlira  is 
underrated,  and  fistulaj  wiiich  do  not  get  well  owe  their  intractability 
to  the  fact  that  the  stricture  has  not  been  brought  to  the  full  size  of 
the  canal.  If  the  urine  can  flow  out  freely  enough,  it  will  choose  the 
larger  and  neglect  the  smaller  channel,  allowing  the  latter  to  heal.  A 
search  iu  tue  track  of  fistula?  which  refuse  to  close  will  sometimes  re- 
veal stone  as  the  cause. 

Where  from  the  mismanagement  of  ])revious  abscess  there  are  nu- 
merous fistula?,  opening  in  all  directions  around  the  penis,  scrotum, 
and  perinreum,  running  through  indurated  tissue,  and,  perhaps,  lined 
by  calcareous  matter  ;  or  where  fistulse  coexist  with  abscess  in  the 
perin^eum,  or  a  lumpy  induration  of  some  extent  around  the  urethra — 
in  any  of  these  conditions  sound  surgery  calls  for  external  perineal 
urethrotomy.  The  incision  should  be  central,  all  abscesses  and  fistu- 
lous tracts  being  opened  into  this,  and  everything  forced  to  heal  from 
the  bottom. 

When  a  fistula  has  one  opening  in  the  rectum,  the  obstacle  to 
success  of  treatment  is  often  the  passage  of  fecal  matter  and  gases  into 
the  urethra.  If,  after  cure  of  the  stricture,  simple  means  (cautery, 
incision)  fail,  a  sliding  operation  of  the  rectal  mucous  membrane  may 
be  called  for,  after  stretching  the  sphincter.  Thompson  mentions  a 
case  which  got  well  in  a  few  weeks  by  position,  the  patient  passing 
water  only  while  lying  upon  his  face.*  John  Chiene  f  cured  four  cases 
of  perineal  fistula,  which  had  resisted  ordinary  means,  by  siphon 
drainage,  i,  e.,  tying  iu  a  soft  catheter  and  attaching  to  it  a  long  rub- 
ber tube  trained  over  the  side  of  the  bed,  and  terminating  in  a  bottle 
of  carbolized  fluid.  He  claims  advantage  for  the  same  method  in  the 
treatment  of  recto-urcthral  fistula  and  for  chronic  cystitis. 

{g)  Pericystitis,  or  Advanced  Interstitial  Cystitis. — In  nearly  all 
cases  of  stricture  there  is  necessarily  more  or  less  cystitis  (inflammation 
of  the  mucous  lining  of  the  bladder),  esi)ecially  about  the  neck,  but, 
in  the  majority  of  cases,  the  bladder  complication  does  not  influence 
in  any  degree  the  treatment  which  the  general  conditions  of  the  strict- 
ure call  for.     Where,  however,  active  interstitial  cystitis  complicates 

*  "  Discascp  of  Urinary  Organ-;,"  4th  cd.,  ISYG,  p.  M6. 

f  Paper  read  before  Medico  Ghirurgical  Society  of  Edinburgh,  November  3,  1880. 


COMPLICATED   BY   ENLARGED   PROSTATE.  lC)?j 

a  tight  stricture,  or  wlicro  the  mnscuhir  substance  of  the  bladder  and 
surrounding  tissues  are  much  involved,  rest  must  be  given  to  the 
bladder,  and  this  is  usually  best  effected  by  external  urethrotomy,  if 
any  active  measures  are  allowable  ;  otherwise  a  supporting  and  stimu- 
lating general  treatment  gives  Nature  the  only  chance  (and  that  a  poor 
one)  of  bringing  the  patient  safely  through.  Particularly  in  all  cases 
of  cystitis  is  it  necessary  to  make  the  urine  unirritating  as  it  flows  from 
the  kidney,  to  alkalinize  it  through  the  stomach,  that  it  may  be  less 
alkaline  at  the  meatus.  G,  Owen  Eees*  has  demonstrated  the  possi- 
bility of  doing  this,  by  giving  alkalies  by  the  mouth,  thus  rendering 
the  urine  alkaline  or  neutral  at  the  kidney.  Alkaline  urine,  with  a 
fixed  alkali,  does  not  irritate  the  bladder,  and  consequently  less  mucus 
]s  secreted  (than  when  the  urine  was  acid),  to  act  as  a  ferment,  decom- 
pose the  urea,  and  give  rise  to  the  formation  of  carbonate  of  ammonia, 
that  powerful  volatile  alkali  which  is  the  agent  in  decomposing  urine 
most  active  in  irritating  and  inflaming  the  bladder,  and  which,  indeed, 
gives  the  alkaline  reaction  to  the  urine  of  chronic  cystitis.  Lemon- 
juice  in  quantity  and  benzoic  acid  will  render  the  urine  of  a  healthy 
individual  acid ;  not  so  when  the  bladder  is  inflamed  ;  then  alkalies 
are  more  likely  to  produce  the  desired  effect. 

{h)  Enlarged  Prostate. — The  complication  of  stricture  by  enlarged 
prostate  is  not  of  common  occurrence.  The  situation  is  always  grave 
when  the  two  conditions  coexist,  if  the  enlargement  of  the  prostate  is 
sufficient  to  interfere  with  the  passage  of  instruments  into  the  bladder, 
and  the  stricture  is  situated  as  deep  as  the  bulb,  or  beyond  it.  The 
tighter  the  stricture  the  more  serious  does  the  complication  become, 
and,  should  retention  supervene,  the  difficulty  of  the  situation  is  appar- 
ent at  once,  whether  the  obstacle  to  the  escape  of  urine  be  situated  at 
the  strictured  point  or  in  the  prostate. 

If  the  stricture  is  in  the  pendulous  urethra,  it  should  be  cut  inter- 
nally. If  the  stricture  is  deep  but  not  very  tight,  a  silver  catheter  of 
long  curve  should  be  selected,  which  will  enter  the  bladder  through 
the  enlarged  prostate,  and  steel  conical  dilating  instruments  should 
be  constructed  of  the  same  curve.  When  the  urethra  has  been 
■dilated,  the  sound  may  be  replaced  by  the  catheter  to  be  habitually 
used. 

If  the  stricture  is  very  small,  so  as  to  admit  only  a  filiform  bou- 
gie, especially  if  there  be  retention,  perineal  section,  an  incision  of 
the  prostate  in  the  median  line,  and  tying  in  a  large  rubber  tube  is  the 
proper  expedient.  If  a  cutting  operation  is  objectionable  for  any 
reason,  the  method  known  as  "  continuous  dilatation "  may  be  re- 
sorted to. 

Continuous  Dilatation. — The  execution  of  the  treatment  and  its 

*  On  the  "  Pathology  and  Treatment  of  Alkaline  Conditions  of  the  Trine,"  Guy's 
Hospital  Reports,  Third  Series,  vol.  i,  1855,  pp.  300,  301. 


164:  TREATMENT   OF   STRICTURE   OF   THE   URETHRA. 

action  arc  as  follows  :  A  filiform  bouf;:ie,  whalebone  or  soft,  is  passed 
through  the  stricture,  which  "grasps  ''  it  tightly,  and  is  tied  in.  The 
first  action  of  this  instrument  upon  the  stricture  is  to  cause  irritation. 
The  muscular  fibers  at  the  strictured  point  grasp  the  instrument  and 
hold  it  tightly.  This  continues  for  a  while  and  tiien  subsides  ;  mean- 
time, if  the  patient  tries  to  pass  water,  he  finds  himself  unable  to  do 
so.  Soon  the  spasm  relaxes  and  the  urethra  widens  notably,  so  that 
a  few  hours  later  the  patient  can  make  water  easily  alongside  the  in- 
strument. A  knowledge  of  this  fact  relieves  all  fear  of  retention  in 
connection  with  this  style  of  treatment ;  the  fear  is,  indeed,  on  the 
other  side,  for  if  a  soft  filiform  instrument  has  been  tied  in,  no  matter 
how  tightly  it  was  embraced  by  the  stricture  at  the  moment  of  intro- 
duction, the  chances  are  th'at  at  the  second  or  third  micturition  it  will 
be  doubled  up  and  washed  bodily  out  of  the  canal  by  the  volume  of 
the  stream  of  urine.  This  is  not  so  apt  to  happen  where  there  is  also 
enlarged  prostate,  on  account  of  the  smallness  of  the  stream  and  the 
atony  of  the  bladder  frequently  attending  that  condition.  After  the 
instrument  has  been  tied  in  for  twenty-four  hours,  the  stricture  will 
readily  admit  a  larger  bougie.  This  should  be  tied  in  the  same  way. 
The  stricture  ulcerates  superficially,  but  widens  Avith  great  rapidity. 
After  it  has  reached  a  certain  size,  it  may  be  treated  by  dilatation  as 
described  above. 

There  are  objections  to  the  treatment  of  stricture  by  continuous 
dilatation.  Some  patients  suffer  torments  if  an  instrument  is  tied 
into  the  urethra,  while  urethral  fever  and  epididymitis  are  often 
caused  by  it.  On  the  other  hand,  some  patients  support  it  with  per- 
fect impunity,  even  when  walking  about.  If  severe  chills  come  on 
during  continuous  dilatation,  it  is  prudent  to  withdraw  the  instru- 
ment ;  if  the  chills  are  mild,  they  may  be  disregarded.  Strictures  en- 
larged by  continuous  dilatation  commence  to  recontract  at  once  with 
great  rapidity,  unless  they  are  kept  dilated  by  the  occasional  use  of 
the  sound. 

3.  Fistula  with  Loss  of  Substance.* 

Fistulas  of  the  urethra  with  loss  of  substance  may  result  from  gan- 
grene, abscess,  phagedenic  ulceration,  simple  ulceration  (the  tying  in 
of  a  silver  catheter  for  a  length  of  time).  They  are  seen  usually  as  the 
result  of  infiltration  and  abscess  complicating  stricture.  In  this  va- 
riety of  fistula  a  hole  exists  in  the  floor  of  the  urethra,  through  which 
its  roof  is  visible.  As  has  been  shown,  small  fistulas  close  on  dilating 
the  urethra.  The  same  law  which  causes  a  traumatic  stricture  to 
close  entirely,  if  all  urine  escape  through  fistulpe  behind  it,  will  the 
more  certainly  close  a  small  fistula,  unless  from  obstruction  in  front 
of  it,  and  consequent  distention  of  the  urethra  during  urination,  fluid 
be  forced  into  its  internal  orifice.     AVith  loss  of  substance,  however, 

*  AH  large  fistulae  are  considered  here,  whether  complicating  stricture  or  not. 


FISTULA   WITH   LOSS   OF  SUBSTANCE.  Ifj5 

dilatation  of  the  urethra,  though  necessary  for  cure,  will  not  alone 
suffice.  If  the  opening  is  larger  than  a  pea,  its  closure  is  often  diffi- 
cult, especially  if  it  lie  anterior  to  the  peno-scrotal  angle.  The  causes 
of  failure  here  are  three  : 

1.  The  thinness  of  the  natural  tissues  furnishing  only  narrow  edges 
for  the  union  of  flaps. 

2.  The  difficulty  of  avoiding  contact  of  urine  with  the  cut  edges. 

3.  The  disturbance  of  the  wound  on  account  of  changes  in  size  of 
the  organ  (erection). 

Where  loss  of  substance,  however,  is  not  very  great,  if  there  be  no 
urethral  obstruction  in  front  of  the  fistula,  repeated  cauterizations 
may  effect  a  cure.  In  this  way  Sir  Astley  Cooper*  closed  a  fistula  as 
large  as  a  pea  with  nitric  acid,  after  two  operations  with  harelip  pins 
and  interrupted  suture  had  failed.  He  states  that  this  plan  will  not 
succeed  unless  the  integument  is  loose,  and  the  scrotum  forms  part  of 
the  orifice  of  the  fistula.  Dieffenbach  f  prefers  a  concentrated  tincture 
of  cantharides  for  small  openings,  which  he  applies  as  follows  :  The 
urethra  is  distended  over  a  full-sized  bougie,  and  the  tincture  applied 
with  a  small  brush  to  the  inner  border  of  the  fistula.  This  manoeuvre 
is  repeated  several  times  in  the  twenty-four  hours.  The  epithelium 
as  it  loosens  must  be  scraped  away,  and  the  tincture  applied  to  the 
raw  surface  until  healthy  granulations  have  sprung  up,  which  seem 
capable  of  closing  the  opening.  Failing  once,  the  treatment  may  be 
repeated. 

If  this  is  not  sufficient,  or  if,  at  first,  the  opening  seemed  too  large 
to  warrant  the  simple  application  of  caustic,  its  use  may  be  combined 
with  that  of  Dieffenbach's  lace  suture  (Schniirnaht),  which  is  applied 
as  follows  :  After  the  epithelium  has  been  removed  by  the  application 
of  the  tincture  of  cantharides,  as  just  detailed,  and  a  large,  soft  bou- 
gie has  been  passed  into  the  urethra,  a  small  curved  needle,  not  cut- 
ting at  the  sides,  carrying  a  stout  (waxed)  silk  ligature,  is  introduced 
with  a  needle-holder  at  about  three  lines  from  the  border  of  the  fistula. 
The  point  of  the  needle  must  not  enter  the  urethral  canal,  but,  after 
traveling  a  short  distance  in  the  substance  of  the  corpus  spongiosum, 
it  is  made  to  emerge  through  the  integument  at  a  point  also  about 
three  lines  distant  from  the  edge  of  the  fistula.  The  needle  is  rein- 
troduced at  the  same  puncture  whence  it  emerged,  and  the  same 
stitch  is  repeated  often  enough  to  carry  the  thread  around  the  fistula 
at  a  distance  of  about  three  lines  from  it,  and  to  make  it  finally  ter- 
minate through  the  puncture  in  the  integument  where  it  first  entered, 
thus  leaving  the  two  ends  of  the  thread  emerging  from  the  same  cu- 
taneous orifice,  the  thread  itself  lying  in  the  corpus  spongiosum,  and 
the  urethra  not  having  been  punctured  by  the  needle.     By  gently 

*  "Surgical  Essays,"  London,  1819,  p.  205. 
f  "Die  Operative  Chirurgie,"  Lcipsic,  1845. 


166  TREATMENT   OF   STRICTURE   OF   THE   URETHRA. 

pulling  upon  the  two  strings,  the  raw  edges  of  the  fistula  arc  now 
brought  together.  The  ligature  is  tied,  the  knot  sinking  into  the 
cellular  tissue  :  the  sound  is  withdrawn,  and  water-dressing  employed. 
The  iVaticnt  urinates  through  a  catheter.  In  three  or  four  days  the 
ligature  is  cut  and  gently  drawn  out.  Two  operations  may  be  re- 
quired, the  first  rendering  the  fistula  smaller,  the  second  obliterating 
it.  This  lu'ocedure  is  applicable  to  all  fistulae  of  the  spongy  urethra 
of  less  than  one-sixth  inch  diameter. 

"Where  the  opening  is  larger,  urethroplasty  is  required.  Of  the 
many  operations  which  have  been  proposed,  undoubtedly  that  of  Sy- 
manowsky  is  the  best.  It  is  applicable  to  all  parts  of  the  urethra. 
Symanowsky  proposed  it  in  1870  for  the  anterior  urethra  alone. 
Weir  *  first  performed  it  successfully  in  this  country.  Sabine  first 
adopted  it  for  the  perina?um,  and  McBurney,t  in  an  admirable  paper, 
clearly  detailed  his  experience  with  it  in  six  perineal  cases,  five  of  which 
■were  successful.  The  operation  exposes  two  large,  raw,  flat  surfaces 
to  each  other,  and  covers  the  fistula  with  a  double  thickness  of  flap. 
I  have  found  the  operation  very  easy  of  execution. 

A  straight  incision  in  the  skin  is  made  through  the  center  of  the 
fistula  in  the  pendulous  urethra,  at  its  right  edge  in  the  pcrinaBum — 
always  in  the  long  axis  of  the  urethra.  The  parts  must  be  clean  washed 
and  shaven,  and  it  is  better,  if  hairs  occupy  the  flap  which  is  to  be 
turned  in,  that  they  should  be  removed  by  electrolysis  as  a  first  step 
in  the  operation.  The  edges  of  the  fistula  must  be  scraped  and 
cleaned  of  all  suppurating  granulations.  The  length  of  incision  in  the 
anterior  urethra  varies  with  the  size  of  the  fistula.  In  the  perinaeum 
the  incision  commences  three  quarters  of  an  inch  in  front  of,  and  ter- 
minates at  the  same  distance  behind,  the  fistula.  The  incision  goes 
through  the  superficial  fascia.  On  the  patient's  right  of  this  incision, 
the  skin  and  superficial  fascia  are  dissected  up  to  form  a  half-oval 
pocket,  sufficiently  deep  to  take  in  the  flap,  to  be  turned  over  from 
the  other  side.  On  the  patient's  left  of  the  first  incision,  a  half-oval 
flap  is  made  of  skin  and  superficial  fascia.  Its  greatest  width  in  the 
perinfflum  is  three  quarters  of  an  inch.  This  flap  is  dissected  up  toward 
the  median  line  until  it  can  be  turned  over  as  upon  a  hinge.  Enough 
tissue  is  left  at  the  hinged  line  to  insure  the  vitality  of  the  flap.  The 
cutaneous  surface  of  this  flap  is  freely  rawed  with  curved  scissors,  ex- 
cept over  that  part  which,  when  the  flap  is  turned  over  into  its  place, 
covers  the  fistula. 

Catgut  sutures,  passed  from  the  patient's  right  edge  of  the  under- 
mined flap  into  the  pocket,  take  in  the  free  edge  of  the  flap  to  be  in- 
verted, and  are  again  passed  through  the  pocket  and  out  upon  the 
surface  near  the  point  of  entrance.     In  this  way  a  number  of  loops 

*  "  New  York  Medical  Record,"  April  13,  1878,  p.  286. 

f  "New  York  Medical  Journal,"  November  6,  1886,  p.  513. 


SUMMARY    OF   TREATMENT   OF   STRICTURE.  107 

a,re  formed,  with  which  the  inverted  flap  is  i)ocketcd  and  drawn  snugly 
into  place.  A  few  more  catgut  sutures  are  passed  from  the  surface 
of  the  undermined  flap  through  the  raw  surface  of  the  inverted  flap, 
and  serve  to  bind  the  raw  surfaces  together.  Finally,  the  edge  of  the 
undermined  flap  at  the  line  of  the  first  incision  is  united  by  many 
points  of  suture  to  the  curved  edge  on  the  other  side,  from  which  the 
inverted  flap  has  been  cut  away.  Bichloride  irrigation,  iodoform, 
cotton,  and  a  T-bandage  with  pressure,  complete  the  dressing.  An 
opiate  confines  the  bowels  at  first,  and  a  catheter  is  used  for  many 
days  every  time  the  patient  urinates,  the  bladder  being  washed  with  a 
solution  of  borax  each  time  the  catheter  is  used.  One  of  McBurney's 
cases  took  over  three  months  to  get  well.  The  other  four  were  healed 
in  seventeen,  thirteen,  nineteen,  and  thii^ty-four  days  respectively. 
Of  course,  in  all  these  cases,  the  entire  urethra  must  be  freed  from 
stricture  before  the  cure  of  the  fistula  is  attempted. 

In  closing  a  very  large  fistula  of  the  anterior  urethra,  the  expedi- 
ent first  suggested  by  Segalas  and  Eicord  *  may  be  adopted,  namely, 
opening  the  bladder  through  the  perinseum  for  drainage.  At  the  pres- 
ent date,  in  such  cases,  a  rubber  tube  is  tied  in  ;  but  this  prejoaratory 
puncture  of  the  urethra  can  usually  be  dispensed  with  by  a  careful 
operator. 

SUMMARY    OF    TREATMENT    OF    STRICTURE. 

1.  Alkalies,  diluents,  and  rest  are  serviceable  in  most  cases  of 
stricture — sometimes  indispensable  if  there  be  any  serious  complica- 
tion. 

2.  All  uncomplicated  strictures,  not  highly  irritable  or  resilient, 
should  be  treated  by  dilatation  with  soft  instruments  up  to  No.  15, 
conical  steel  sounds  afterward ;  reintroductions  being  made  every 
fourth  to  eighth  day — the  older  the  stricture  the  longer  the  interval 
as  a  rule,  and  intervals  of  one  week  being  most  serviceable  in  the 
majority  of  cases. 

3.  All  strictures  of  the  meatus  or  pendulous  urethra  should  be  cut. 

4.  Eesilient,  very  irritable,  and,  as  a  rule,  traumatic  strictures  of 
the  deep  urethra  should  be  cut  externally  or  by  combined  internal  and 
external  urethrotomy ;  other  strictures  in  this  region  should  be  treated 
by  ordinary  dilatation. 

5.  Impassable  stricture  may  usually  be  overcome — where  there  is 
no  retention — by  time,  patience,  and  skill,  with  whalebone  bougies. 
If  finally  proved  impassable,  the  treatment  is  external  perineal  ure- 
throtomy. 

6.  Eetention  is  treated  by  hot  baths,  ether,  opium,  tincture  of  the 
sesquichloride  of  iron  ;  failing  these,  by  puncture  above  the  pubis 

*  "  Monthyon  Prize  Essay,"  1841. 


1(58  TREATMENT   OF   STRICTURE   OF  THE   URETHRA. 

with  the  aspirator  ;  or  by  external  perineal  urethrotomy  without  a 
guide. 

7.  For  stricture  complicated  by  abscess,  inliltration,  or  many  and 
large  fistulje  and  for  extensive  traumatic  stricture,  external  perineal 
urethrotomy. 

8.  For  inliltration,  free  incisions,  stimulants,  supportives,  with 
thorough  external  division  of  the  stricture, 

9.  For  fistula  with  loss  of  substance,  local  cauterization,  lace  sut- 
ure, or  plastic  operation.  Where  there  is  no  loss  of  substance,  com- 
plete dilatation  of  the  stricture  is  soon  followed  by  closure  of  the 
fistula. 

URETHRAL    CASE    OF    INSTRUMENTS. 

It  is  advisable  to  introduce  here  a  list  of  such  instruments  as  will  be 
necessary  to  make  up  a  case  suitable  to  meet  the  requirements  of  such 
maladies,  demanding  instrumentation  within  the  urethra,  as  are  ordi- 
narily encountered  by  the  general  i^i'actitioner  : 

Gauge. 

Conical  steel  sounds,  Nos.  15  to  33— or  37— twelve  instruments, 
omitting  sizes  of  even  number. 

One  long  and  several  short  whalebone  filiform  guides. 

One  Banks's  whalebone  bougie. 

One  silver  catheter,  No.  6,  very  short  curve,  tunneled. 

Several  larger  silver  catheters,  not  tunneled. 

One  female  silver  catheter,  size  18. 

Two  long,  curved  silver  prostatic  catheters,  sizes  15  and  27. 

Thompson's  rapid  dilator,  tunneled. 

Civiale's  urethrotome. 

Otis's  urethrotome. 

Straight  bistoury. 

Gouley's  catheter  staff,  size  18. 

Urethral  forceps. 

Some  silk  elastic,  and  some  Mercier's  soft  catheters. 

A  few  olivary  French  and  a  few  rubber  catheters. 

Conical  soft  French  bougies  (not  olivary),  sizes  5  to  18. 

A  set  of  tunneled  steel  sounds,  6  to  18. 

Metallic  and  soft  bulbous  bougies,  6  to  37,  every  alternate  size. 

Otis's  urcthrameter. 

Probes,  directors,  needles,  knives,  and  silk. 

Eoll  of  rubber  plaster. 

Tube  of  vaseline. 


ANATOMY   OF   THE  PROSTATE.  IQO 


CHAPTER  IX. 

DISEASES  OF  THE  PROSTATE. 

Anatomy. — Function.— Deformities.— Injuries. — Atrophy.— Hypertrophy.— Bar  at  the  Xeck  of  the 
Bladder. — Symptoms  and'  Results  of  Hypertrophy.— Course  of  Symptoms  from  commencing; 
IrritabUity  up  to  Retention,  Atony,  Stone,  Uraemia,  Death. 

AisTATOMY. — The  prostate  (Trpoo-raTT^s,  standing  iefore),  somewhat 
improperly  called  a  gland,  is  a  body  composed  mainly  of  unstriped 
muscle,  placed  like  a  sphincter  around  the  first  inch  of  the  urethra  and 
the  neck  of  the  bladder.  It  contains  multilobular  mucous  glands  in 
its  substance,  and  is  tunneled  by  the  two  ejaculatory  ducts — the  com- 
mon canal  formed  by  the  union  of  the  duct  of  the  seminal  vesicle  with 
the  vas  deferens  on  either  side.  The  ejaculatory  ducts  open,  in  the 
floor  of  the  prostatic  urethra,  on  the  sides  of  the  little  crest  in  the 
median  line  called  veru  montanum.  Here,  also,  most  of  the  ducts  of 
the  mucous  glands  of  the  prostate  open.  The  latter  secrete  a  bluish 
mucus,  which  serves  to  dilute  the  semen  and  possibly  to  prolong  the 
vitality  of  the  spermatozoa.*  Both  the  glands  and  their  ducts,  in  late 
adult  life,  habitually  contain  certain  small  solid  deposits,  called  pros- 
tatic concretions,  formed  in  concentric  layers,  which  seem  to  have  no 
special  significance,  though  they  often  exist  in  vast  numbers,  and  of 
considerable  size.  They  are  occasionally  encountered  in  the  urine. 
The  lower  part  of  the  prostate  is  surrounded  by  a  few  striped  muscu- 
lar fibers — the  external  vesical  sphincter  of  Henle, 

The  prostate  is  a  muscle.  Its  main  function  is  to  contract  on  the 
semen  after  the  latter  has  collected  within  and  distended  the  prostatic 
sinus.  This  contraction  is  coincident  with  the  venereal  orgasm.  It 
is  spasmodic  in  character,  throwing  out  the  seminal  fluid  in  successive 
jets.  The  seat  of  the  venereal  orgasm  is  in  the  nerves  of  the  mucous 
membrane  lining  the  prostatic  sinus,  as  proved  by  the  fact  that  it  is 
sometimes  excited  by  the  passage  of  a  sound  through  the  prostate,  and 
is  not  destroyed  by  amputation  of  the  glans  penis. 

The  prostatic  utricle,  the  analogue  of  the  cavity  of  the  uterus,  is  a 
little  depression  lying  in  the  floor  of  the  prostate  beneath  the  veru 
montanum,  opening  by  a  small  vertical  slit  in  front  of  the  summit  of 
the  latter.  This  cavity  and  the  orifices  of  the  mucous  follicles,  dilated 
by  hydrostatic  pressure  in  cases  of  tight  stricture,  are  liable  to  catch 
the  fine  points  of  filiform  bougies  introduced  through  a  stricture. 

The  base  of  the  prostate  embraces  the  neck  of  the  bladder,  and  sur- 
rounds the  vasa  deferentia  and  necks  of  the  seminal  vesicles.     The 

*  Fiirbringer,  "  Berl.  klin.  Wchnschrft,,"  July  19,  1886. 


170  DISEASES  OF   TUE   PROSTATE. 

prostate  lies  below  and  directly  in  front  of  the  neck  of  the  bladder,  in- 
closed by  a  fibrous  capsule,  in  relation  with  the  pubes  in  front,  the 
rectum  behind,  and  held  in  ]ilace  mainly  by  the  jielvic  fascia — or  pos- 
terior layer  of  the  triangular  ligament — and  the  pubio-prostatic  liga- 
ment in  front.  There  is  never  any  fat  between  the  rectum  and  pros- 
tate. A  large  plexus  of  veins  surrounds  the  prostate  in  front,  and 
above  as  well  as  (partly)  below. 

The  prostate  is  composed  of  two  lateral  lobes,  and  only  two.  They 
form  one  symmetrical  body,  and  never  remain  distinct  in  man,  as 
they  do  in  some  animals.  Thompson,  quoting  Morgagni,  Santorini, 
Hunter,  Cruveilhier,  and  others,  as  well  as  concluding  from  his  own 
minute  investigations,  decides  absolutely  against  tlie  existence  of  any 
third  or  median  lobe  in  the  healthy  prostate. 

In  shape  and  size  the  organ  resembles  an  Italian  chestnut.  Its 
weight  is  about  half  an  ounce.  It  lies  with  its  apex  looking  forward, 
and  may  be  readily  felt  during  life  through  the  rectum.  The  finger 
can  always  reach  above  its  posterior  border,  unless  the  organ  is  de- 
cidedly enlarged. 

The  prostate  is  a  genital,  not  a  urinary  organ.  Like  the  rest  of 
the  genital  apparatus,  it  is  small  before  puberty,  and  becomes  notably 
developed  during  that  epoch.  Its  average  diameters  in  the  healthy 
adult*  are,  longitudinal  25  to  30  millimetres,  transverse  32  to  40,  thick- 
ness 20  to  25  ;  or,  roughly,  1|-,  Ij,  f  inch.  The  urethra  usually  tunnels 
its  upper  part,  but  occasionally  its  lower  portion,  in  which  case  it  is 
only  slightly  separated  from  the  rectum,  a  circumstance  which  exposes 
the  latter  to  injury  in  the  cutting  operation  for  stone.  The  prostatic 
urethra  is  surrounded  by  a  small  amount  of  erectile  tissue. 

The  arteries  of  the  prostate  come  from  the  vesical  and  middle 
h£emorrhoidal.  Its  veins  discharge  into  the  surrounding  venous 
plexus,  Avhich  is  made  up  by  their  union  with  the  dorsal  veins  of  the 
penis  and  the  veins  of  the  bladder.  The  lymphatics  communicate 
with  the  lymphatic  glands  on  the  sides  of  the  pelvis.  The  nerves 
come  from  the  hypogastric  plexus. 


DEFORMITIES  OF  THE  PROSTATE. 

Deformities  of  the  prostate  are  exceedingly  rare.  Its  roof  is  open 
in  extrophy  of  the  bladder,  but  its  floor  never  seems  to  fail.  It  is 
never  wanting  except  in  connection  with  extensive  lack  of  development 
of  the  whole  genital  system,  particularly  with  non-development  of  the 
testicles.  After  complete  castration  on  both  sides,  the  prostate  has 
been  seen  to  disappear,  f 

*  Cruveilhier,  op.  cit,  p.  395. 

f  Civiule,  quoted  by  Pitha,  op.  cil.,  p.  V2Y. 


INJURIES— ATKOPIIY.  171 

INJITRIES   OF   THE   PROSTATE. 

The  prostate  by  its  position  is  well  protected  from  ordinary  casual- 
ties, and  rarely  suffers  unless  the  general  injury  is  very  extensive,  in 
which  case  its  implication  may  be  considered  unimportant. 

The  ivounds  of  the  prostate  are  incised  wounds  made  in  the  opera- 
tion for  stone,  lacerated  wounds  in  the  same  operation  from  introduc- 
ing dilating  instruments,  or  extracting  a  large,  rough  stone,  and  pene- 
trating wounds  (false  passage)  made  by  accident  or  design  in  trying 
to  pass  a  metallic  instrument  of  an  improper  curve  through  an  ob- 
structed urethra.  The  prostate  is  a  patient  organ,  and  bears  all  these 
injuries  well.  Healing  after  stone  operations  is  exceptionally  ra])id, 
and  the  prostate  may  be  punctured  by  a  catheter  without  necessarily 
any  evil  consequence,  unless  it  be  the  seat  of  chronic  disease.  Injuries 
to  the  prostate  get  well,  usually,  if  let  alone,  even  where  abscess  forms 
in  the  organ,  and  abscess  is  not  frequent  even  after  pretty  extensive 
laceration,  although  the  parts  are  constantly  bathed  in  urine.  Inju- 
ries of  the  prostate  do  not  excite  much  constitutional  derangement. 
Very  different,  however,  is  the  case  if  the  injury  extends  beyond  the 
limit  of  the  fibrous  capsule  of  the  gland.  In  such  cases  the  worst 
complications  are  to  be  feared  (pelvic  infiltration,  abscess,  peritonitis), 
and  if  the  patient  escape  with  his  life  he  is  fortunate.  These  conse- 
quences are  more  apt  to  occur  in  the  operation  for  extraction  of  very 
large  stone.  The  only  treatment  consists  in  seeing  that  the  urine  is 
thoroughly  drained  off,  and  supporting  the  patient's  strength,  keeping 
him  at  rest,  and  using  opium  as  required. 

ATROPHY    OF   THE    PROSTATE. 

Atrophy  of  the  prostate  is  rare,  but  is  occasionally  encountered. 
Among  the  recognized  causes  may  be  mentioned  the  atrophy  of  old 
age,  coinciding  with  general  atrophy  of  the  rest  of  the  body.  Here 
the  glandular  rather  than  the  muscular  constituent  disappears. 
Thompson,  in  his  admirable  monograph,  which  obtained  the  Jack- 
sonian  prize  in  I860,*  has,  by  laborious  investigation,  established  the 
fact  that  the  prostate  does  not  necessarily  enlarge  with  age,  nor  does 
it  necessarily  atrophy.  As  a  rule,  it  continues  about  of  normal  size, 
but  it  may  occasionally  atrophy,  physiologically,  like  other  structures 
in  old  age,  Just  as  it  may,  and  often  does  (pathologically),  hypertrophy. 
Atrophy  of  the  prostate,  during  general  wasting  disease,  especially 
phthisis,  has  been  noted.  Pressure  from  a  tumor,  or  cyst,  or  stone, 
within  or  near  the  prostate,  may  cause  its  atrophy,  as  may  also  the 
constant  pressure  of  urine  behind  a  tight  stricture.  Atrophy,  after 
double  castration,  is  possible. 

Atrophy  of  the  prostate  has  no  symptoms  except,  possibly,  lack  of 
*  "  On  the  Diseases  of  the  Prostate,"  4th  ed.,  1873. 


172  DISEASES   OF   THE   PROSTATE. 

force  in  the  ejection  of  semen.  It  is  an  unimportant  allection,  and 
has  no  direct  treatment.  If  the  cause  can  be  discovered  and  removed 
(pressure),  the  tendency  to  atropliy  may  be  overcome. 


HYPERTROPHY    OF   THE   PROSTATE. 

The  morbid  condition  to  \vhich  the  ])rostate  is  most  liable  is  h^'per- 
trophy,  either  general,  partial,  or  by  the  development  of  circumscribed 
tumors.  In  general  hypertrophy  the  glandular  elements,  instead  of 
being  hypcrtrophied,  often  become  atrophied  by  the  excessive  growth 
of  fibrous  and  muscular  tissue  between  them.  In  marked  cases  they 
are  completely  destroyed,  and  the  prostate  is  converted  into  a  homo- 
geneous fibro-muscular  tumor.  The  isolated,  circumscribed  prostatic 
tumors,  however,  always  show  new^  formation  of  gland-tissue.* 

Cause. — The  cause  of  hypertrophy  of  the  prostate  is  totally  un- 
known. The  numerous  hj^potheses  w^hich  have  been  advanced  by 
authors  need  not  be  discussed  :  they  do  not  cover  the  ground.  No 
known  diathesis,  or  combination  of  circumstances,  can  account  for  the 
affection.  It  is  not  venous  stasis,  or  excessive  use  of  the  organ,  or 
sedentary  life.  All  that  can  be  said  is,  that  the  disease  does  not  occur 
before  middle  age — rarely  before  fifty  ;  Thompson  sa^^s  fifty-five. 

The  prostate  is  analogous  to  the  uterus  in  the  female  in  regard  to 
the  nature  of  the  muscular  tissue  which  composes  it,  and  this  analogy 
is  further  borne  out  by  the  tendency  of  both  organs  to  develop  fibrous 
tumors  (so  called)  after  middle  life.  Velpeau  f  suggested  this  analogy, 
and  justly.  The  portion  of  jirostatic  tissue  which  hypertrophies  is 
the  muscular  and  not  the  glandular  (or  only  to  a  small  extent),  and 
although  general  or  partial  enlargements  of  the  prostate  are  the  rule, 
yet  it  is  rather  rare  for  any  considerable  hypertrojjhy  of  the  organ  to 
be  found  without  the  coexistence  of  one  or  more  circumscribed  tu- 
mors, which  correspond  to  the  circumscribed  fibrous  tumors  of  the 
uterus,  also  composed  mainly  of  unstriped  muscle.  Bayle  says  that 
twenty  per  cent  of  women,  after  thirty-five,  have  fibrous  tumors  of 
the  uterus,  the  cause,  of  course,  unknown.  Thom2)son  says  that 
thirty  per  cent  of  males,  after  fifty,  have  fibrous  tumors  of  the  pros- 
tate, lie  states  that  moderate  enlargement  of  the  prostate  may  be 
expected  in  one  out  of  three  men  ;  after  fifty,  marked  enlargement  in 
one  out  of  ever}'  eight,  but  rarely  before  sixty.  Thompson  believes  that 
the  affection  rarely  commences  after  seventy.  He  quotes,  from  Beith,  J 
the  case  of  an  old  man  who  died  at  one  hundred  and  three,  where  the 
only  abnormal  conditions  found  were  hypertroiihy  of  the  prostate  and 
a  sacculated  bladder. 

*  Rindflciscb,  "  Path.  Histology,"  Anier.  trans.,  p.  546. 
f  "  Le9ons  Orales,"  vol.  iil,  Paris,  1841,  p.  478. 
X  "Trans.  Path.  Soc,"  1850-'51,  p.  124. 


HYPERTROniY. 


173 


Size  and  Shape. — No  positive  limit  in  size  can  bo  named.  The 
prostate  may  be  encountered  of  the  size  of  a  man's  fist.  Thompson 
has  seen  the  transverse  diameter  exceed  four  and  a  half  inches.  The 
weight  of  twelve  ounces  has  been  reached.  This  excessive  amount  of 
enlargement,  however,  is  rare — a  prostate  as  large  as  a  small  orange 
being  infrequent. 

The  mass  may  take  any  shape,  depending  upon  the  part  of  the 
organ  involved.  Smooth  and  round  in  general  hypertrophy,  it  be- 
comes more  or  less  irregular  in  unsymmetrical  overgrowth,  or  from 
circumscribed  tumors. 

The  portion  most  frequent- 
ly involved,  either  alone  or 
(usually)  associated  with  more 
or  less  general  hypertrophy, 
is  the  posterior  median  part, 
known  since  Sir  Everard 
Home  *  as  the  third  lobe. 
This  nomenclature,  however, 
is  inexact.  The  prostate  has 
no  third  lobe,  and  what  Home, 
from  his  dissection  of  diseased 
prostates,  named  the  "  third 
lobe,"  is,  in  reality,  a  patho- 
logical formation,  and  is  now 
more  correctly  styled  median 
centric  hypertrophy.  It  con- 
sists of  that  triangular  part 
of  the  prostate  lying  between 
the  ejaculatory  ducts,  and 
overgrowth  in  this  situation 
is  believed  to  be  due  to  the 
absence  of  capsule  here.  It 
may  be  found  with  little  or  no 
enlargement  elsewhere.  In 
form  it  is  usually  an  oval,  rounded  tumor  (there  maybe  two  or  more), 
which  grows  up  from  the  floor  of  the  back  part  of  the  prostatic  ure- 
thra and  juts  out  posteriorly  into  the  cavity  of  the  bladder.  It  may 
reach  the  size  of  a  small  pear,  and  indeed  resemble  a  pear  in  shape, 
showing  a  tendency  to  pedunculation. 

When  hypertrophy  invades  the  lateral  lobes,  only  one  may  be  af- 
fected, but  usually  both,  more  or  less  general  enlargement  correspond- 
ing with  the  local  overgrowth  (Fig.  54).  Under  these  circumstances 
the  pyriform  central  tumor  tends  to  fill  up  the  internal  orifice  of  the 

*  "Philosophical  Transactions,"  1806,  paper  viii.  It  was  not  disccverod  by  Home. 
It  was  accurately  described  by  Santorini  in  1739,  and  mentioned  by  Morgagni. 


Fig.  54  {Coulson). 

Showing  enlarffed  prostate  with  "  third  lobe."  through 

the  base  of  which  a  false  passage  has  been  made. 


174 


DISEASES  OF  THE  PROSTATE. 


iiretlira,  leaving  a  passage  on  either  side  along  its  lloor  for  the  urine. 
The  mucous  membrane  on  either  side  of  the  central  mass  is  often 
drawn  uj)  between  it  and  the  hyjiertrophicd  lateral  lobes,  forming  a 
cresceutic  bar  at  the  neck  of  the  bladder. 

Imbedded  in  the  hypertrophied  mass,  it  is  usual  to  ilnd  several 
small  circumscribed  tumors,  dense,  hard,  seemingly  fibrous  in  charac- 
ter, easily  enucleated  and  elastic,  so  that,  when  cut  through  in  a  clean 
section  of  the  organ,  the  cut  surface  of  the  tumor  overrides  the  general 
smooth  plane  of  the  incision,  as  if  the  little  mass  had  previously  been 
compressed.  They  are  formed  of  unstriped  muscle  with  some  new 
glandular  tissue,  and  are  considered  analogous  to  mammary  glandu- 
lar tumors,  or  to  the  glandular  bodies  which  develop  (pathologically) 
in  and  around  the  thyroid.  These  tumors,  usually  small,  may  become 
as  large  as  a  marble  ;  many  are  found  of  the  size  of  a  pea. 

Occasioualh^,  when  the  urethra  runs  an  anomalous  course  through 
the  lower  part  of  the  prostate,  the  upper  part  alone  may  hypertrophy. 
A  remarkable  instance  of  this  unusual  form  of  hypertrophy  is  figured 
by  Quain,*  quoted  and  refigured  by  Stein  f  (Fig.  55). 


Fio.  55. 

Other  localized  hypertrophies  of  the  prostate  are  more  rarely  en- 
countered in  the  shaiie  of  distinctly  pedunculated  tumors,  which  grow 
from  any  portion  of  the  posterior  margin  of  the  prostate,  and  hung 
into  the  cavity  of  the  bladder.  They  may  surround  the  neck  of  the 
bladder  like  a  fringe.  ^Median  centric  hypertrophy  may  take  this 
form,  constituting  a  sort  of  ball-and-socket  valve  at  the  neck  of  the 
bladder.     Finally  there  may  develop  in  the  thickness  of  the  bladder- 

*  "Medical  Times  and  Gazette,"  May,  1872. 

f  "New  York  Medical  Journal,"  May,  ISY^,  vol.  i,  p.  483 


MEDIAN   POSTERIOR   IIYrERTROT'IIY.  175 

walls  small  snpernnmcrary  outlying  prostatic  glandular  tumors,  vary- 
ing in  number  and  in  si;ic,  but  only  existing  coincidently  with  one  of 
the  ordinary  forms  of  overgrowth. 

BAR  AT  THE  NECK  OP  THE  BLADDER. 

This  affection  has  become  classical  since  the  investigations  of  Guth- 
rie,* who  described  the  muscular  bar  formed  by  hypertrophy  of 
bladder-tissue  just  behind  the  prostate,  and  the  bar  of  mucous  mem- 
brane already  alluded  to.  All  the  varieties  of  bar,  of  which  there  are 
three,  may  be  considered  at  once,  in  connection  with  prostatic  hyper- 
trophy : 

1.  Centric  median  hypertrophy,  where  a  transverse  bar  of  hyper- 
trophied  tissue  is  formed,  instead  of  the  usual  oval  tumor  ;  this  form 
is  rare. 

2.  The  lifting  up  of  a  fold  of  mucous  membrane  between  unsym- 
metrical  lateral  lobes,  or  between  the  so-called  third  lobe  and  hyper- 
trophied  lateral  lobes. 

3.  The  form  of  bar  to  which  Guthrie  s|)ecially  called  attention. 
This  latter  may  (rarely)  exist  without  prostatic  hypertrophy.     Its 

seat  is  in  the  muscular  fibers  which  run  transversely  across  the  trigone, 
behind  the  prostate.  These  fibers  sometimes  hypertrophy  greatly,  the 
trigone  becomes  contracted  laterally,  the  orifices  of  the  ureters  ap- 
proach each  other,  while  the  hypertrophied  bands  of  fibers  stand  out 
like  a  bar,  forming  an  obstruction,  but  an  obstruction  totally  uncon- 
nected with  any  prostatic  overgrowth. 

Symptoms  and  Result  of  Enlarged  Prostate. — Hypertrophy  of  the 
prostate  (like  stricture)  does  harm  mechanically,  and  provokes  lesions 
in  other  parts.  Its  symptoms,  pure  and  simple,  are  unimportant,  and 
do  not  call  for  treatment,  unless  the  enlargement  be  sufficient  to 
obstruct  the  free  outflow  of  urine,  and  occasion  disease  of  the  bladder 
(cystitis  and  its  consequences).  A  description  of  the  special  variety 
of  the  latter,  due  to  prostatic  hypertrophy,  finds  its  place  here  more 
naturally  than  under  the  head  of  Diseases  of  the  Bladder. 

The  immediate  result  of  hypertrophy  of  the  prostate  is  a  deviation 
in  the  direction,  and  usually  a  diminution  in  the  size,  of  the  prostatic 
urethra.  As  the  prostate  enlarges,  its  antero-posterior  diameter  elon- 
gates, and  with  it  the  length  of  the  prostatic  urethra  necessarily  in- 
creases. Thompson  has  seen  it  three  inches  long.  The  urethra,  more- 
over, tends  to  become  a  vertical  slit,  as  its  caliber  is  encroached  upon 
from  side  to  side  by  the  increased  size  of  the  lateral  lobes.  If  isolated 
fibrous  tumors  grow  up  from  the  floor  or  sides  of  the  prostatic  ure- 
thra, the  course  of  the  latter  becomes  by  so  much  the  more  devious. 
When  one  lateral  lobe  is  hypertrophied  alone,  or  to  a  greater  degree 

*  "On  the  Anatomy  and  Diseases  of  the  Urinary  and  Sexual  Organs,"  1S36. 


176 


DISEASES   OF   THE   PROSTATE. 


than  its  fellow,  the  urethra  is  pushed  toward  tlie  opposite  side.  When 
there  is  posterior  median  hypertrophy  (as  occurs  in  the  majority  of 
cases  applying  for  treatment),  we  have  the  gi'eatest  degree  of  oblitera- 
tion of  the  canal  for  the  least  amount  of  overorowth.  Most  cases  of 
prostatic  hypertropliy  probahly  never  come  under  the  surgeon's  notice, 
in  consequence  of  there  being  no  obstruction  to  the  outllow  of  urine. 
Many  an  old  man  goes  to  his  grave  with  enlarged  prostate,  the  exist- 
ence of  which  has  never  been  suspected.  Of  those  cases  which  are 
seen,  median  hypertrophy  exists  in  a  large  proportion.  This  median 
central  part  of  the  prostate  lies  at  the  neck  of  the  bladder  directly  in 
the  vesical  orifice  of  the  urethra  (Fig.  56).     As  it  grows  upward  and 


Fig.  56. 

backward,  it  fill.>  the  mouth  of  the  bladder,  and  converts  its  naturally 
rounded  orifice  into  a  crescentic  slit,  convexity  ujjward.  The  floor  of 
the  prostatic  urethra  is  also  unnaturally  tilted  up,  to  override  this 
bulkhead  which  has  sprung  up  in  its  course.  Fig.  57  shows  the  effect 
upon  the  course  of  the  urethra  of  this  so-called  third  lobe,  and  sug- 
gests at  once  the  two  great  facts  which  are  the  key-notes  to  a  correct 
understanding  of  the  pathology  of  hypcrtrophicd  prostate,  and  of  tlie 
means  of  relieving  its  most  prominent  symptom — retention.  These 
facts  are — 

1.  That  such  a  growtli  occupying  the  vesical  orifice,  and  jutting 
out  behind  and  above  it,  must  ob-truct  the  free  outflow  of  the  urine 
from  the  bladder. 

2.  That  an  instrument  of  ordinarv  curve,  introduced  from  witliout, 


HYPERTROniY. 


177 


Fig.  57. — Posterior  median  hypertrophy. 


must  strike  against  this  obstacle,  and  refuse  to  enter  the  bladder.     Con- 
sequently, a  modification  in  the  shape  of  the  instrument  is  called  for. 

The  bar  at  the 
neck  of  the  bladder 
constitutes  an  ob- 
struction of  the 
same  sort.  If  sev- 
eral posterior  tu- 
mors exist,  instead 
of  one,  the  vesical 
orifice  is  corre- 
spondingly modi- 
fied. If  a  single 
pedunculated  tu- 
mor grow  any- 
where around  the 
margin  of  the  ure- 
thral outlet  hang- 
ing into  the  cavity 
of  the  bladder,  it 
may  act  like  a  ball-and-socket  valve,  causing  retention  where  there  is 
very  little  general  hypertrophy. 

To  follow  pathologically  the  natural  history  of  hypertrophy  of  the 

prostate,  it  must  be  borne 
in  mind  that  the  blood,  re- 
turning through  the  vesi- 
cal veins,  finds  its  way 
back  into  the  general  cir- 
culation through  the  ve- 
nous plexus  lying  around 
the  prostate ;  consequent- 
ly any  enlargement  of  the 
latter  tends  to  press  upon 
this  plexus,  and  by  so 
much  to  obstruct  the  ve- 
nous circulation,  and  es- 
tablish a  constantly  in- 
creasing venous  conges- 
tion of  the  bladder  walls 
and  membranes.  Then, 
again,  the  deviation  in  the 
course  of  the  prostatic  ure- 
thra, and  its  decrease  in  size,  mainly  due  to  posterior  central  enlarge- 
ment, obstruct  the  free  outflow  of  the  urine,  and  call  for  constantly 
increasing  efforts  on  the  part  of  the  bladder  to  force  out  its  contents. 
12 


Fig.  58.— Healthy  prostate. 


178  DISEASES  OF  THE  PROSTATE. 

From  these  two  circumstauces,  venous  congestion  and  the  need  for 
an  exercise  of  greater  muscular  power,  the  bladder  walls  go  on  to  hy- 
pertro})hy.  The  bundles  of  fibers  of  the  detrusor  urina^  increase  in 
size,  and  jut  out  into  the  cavity  of  the  bladder,  like  the  colunma?  car- 
nece  of  the  heart.  But  these  thickened  bundles  of  muscular  tissue  do 
not  proportionally  increase  the  expulsive  power  of  the  bladder,  for 
they  are  constantly  congested,  and  working  at  a  disadvantage.  The 
muscular  libers  of  the  base  of  the  bladder  are  not  able  to  contract  suf- 
ficiently to  bring  the  floor  of  the  viscus  above  the  level  of  the  dam  at 
its  mouth,  and  hence  a  little  urine  is  left  behind  after  each  act  of  mic- 
turition. This  residuum  (as  it  is  called)  announces  itself  by  no  symp- 
tom, and  is  unnoticed.  It  becomes  mingled  with  fresh  supplies  of 
urine  coming  down  the  ureters,  and  is  partially  passed  off  and  replaced 
by  fresher  fluid.  After  a  time,  however,  the  mucus,  from  the  slightly 
congested  membrane  around  the  base  of  tiie  bladder,  being  in  part  re- 
tained in  the  residuum,  acts  upon  the  latter,  setting  up  decomiDosition 
of  urea  and  liberation  of  carbonate  of  ammonia. 

The  carbonate  of  ammonia  irritates  the  mucous  membrane  of  the 
bladder,  increases  its  congestion,  and  calls  forth  a  new  supply  of  mu- 
cus, which,  in  its  turn,  acts  as  a  fresh  ferment,  alkalinizing  and  de- 
composing more  urine.  The  natural  acidity  of  the  urine  still  further 
tends  to  keep  up  and  aggravate  the  already  existing  congestion.  Un- 
der these  circumstances — the  membrane  becoming  hypera^mic,  and 
thickened  around  the  already  contracted  mouth  of  the  urethra — more 
obstruction  to  the  outflow  of  urine  is  occasioned,  and  the  quantity 
of  residuum  is  increased,  while  the  laboring  detrusor  urin^e  is  forced 
into  still  greater  hypertrophy  in  its  fruitless  efforts  to  overcome  the 
increasing  obstacle.  In  this  way  the  bladder  becomes  gradually  dis- 
tended, the  amount  of  residual  urine  increasing  from  mouth  to  month, 
and  the  bladder  getting  less  and  less  able  to  empty  itself ,  Hence  with 
hyi^ertrophy  of  the  bladder-walls  there  is,  usually,  also  dilatation  of 
its  cavity. 

Finally,  retention  comes  on,  most  often  excited  by  a  chilling  of  the 
legs,  the  "cold"  which  the  patient  has  taken  "settling,"  as  it  were 
(where  the  circulation  is  already  weakened),  upon  the  prostate  and 
neck  of  the  bladder,  and  superadding  an  active  inflammatory  conges- 
tion to  the  already  existing  enlargement.  Sometimes  the  direct  cause 
of  retention  is  spasm  of  the  deeji  urethral  cut-off  group  of  muscles. 
The  new  hyperemia  may  subside  in  a  few  liours,  if  the  patient  keeps 
quiet  in  a  warm  place,  and  with  its  disappearance  the  power  of  void- 
ing urine  returns  ;  or  surgical  relief  may  be  afforded,  or  the  accumu- 
lation may  go  on  to  overdistention,  and,  finally,  overflow.  This 
stretching  of  the  hypertrophied  but  weak  fibers  of  the  detrusor  takes 
away  more  or  less  of  their  power  of  contraction,  and  the  bladder  is  apt 
to  be  left  in  a  condition  of  atony. 


HYPERTROPHY. 


179 


After  a  retention,  if  it  has  not  lasted  too  lon;:^,  the  bladder  may  go 
on  expelling  the  excess  of  urine  above  the  residuum,  just  as  it  did 
before,  but  now  the  amount  of  residual  urine  is  greater,  and  the  power 
of  the  bladder  less.  The  congested  membrane  around  the  vesical  neck 
and  in  the  prostatic  urethra  is  kept  irritated  by  the  partly  decomposed 
urine,  and  it  takes  but  a  slight  cause,  a  chilling  or  an  excess  at  table, 
to  bring  on  another  retention.  After  each  attack  the  bladder  is  left 
in  a  more  helpless  condition. 

Besides  distention  of  the  bladder  with  hypertrophy  of  its  walls, 
sacculi  may  be  developed  and  grow  greatly  with  each  succeeding  reten- 
tion. The  efforts  which  the 
hypertrophied  fibers  of  the  de- 
trusor are  obliged  to  make  to 
expel  the  urine,  cause  the  mu- 
cous membrane  to  be  pressed 
out  between  their  meshes  into 
little  pouches,  and  if  reten- 
tion come  on,  these  parts, 
being  weaker  than  the  rest  of 
the  bladder,  suffer  most,  and 
may  become  enlarged  into 
supernumerary  bladders  com- 
posed of  mucous  membrane, 
connective  tissue,  and  perito- 
naBum,  but  covered  by  no  mus- 
cular coat  (Fig.  59).  Some- 
times, though  rarely,  one  of 
these  sacculi  may  be  found 
larger  than  the  bladder  itself  * 
— usually  they  are  only  shal- 
low depressions  between  the 
raised  bundles  of  muscular  fibers,  occasionally  little  sacs  with  con- 
stricted necks.  These  sacs  have  no  muscular  tissue,  and  consequently 
no  power  of  emptying  themselves  ;  hence  the  urine  tends  to  stagnate 
in  them,  and  to  undergo  decomposition,  depositing  crystals  of  triple 
phosphate  with  more  or  less  amorphous  phosphate,  etc.,  all  of  which 
become  glued  together  by  mucus,  and  thus  form  a  nucleus  for  stone, 
which,  increasing  in  size,  may  finally  fill  up  the  sacculus  even  with 
its  narrow  neck  (encysted  calculus).  These  changes  are  all  the  more 
certain  if  some  kidney-stone  lodge  in  a  sacculus  instead  of  passing  off. 

This  process  of  stone  formation  which  goes  on  so  readily  in  a 
sacculus,  also  takes  place  in  the  bladder  when  its  floor  is  depressed 
behind  a  third  lobe,  in  what  is  known  as  the  **bas  fond,"  or  lower 
bottom.     Here,  too,  the  urine  stagnates  and  deposits  its  salts,  as  crys- 

*  Gross  mentions  a  case,  in  a  man  of  eighty-four,  where  the  sacculus  held  a  gallon. 


Fig.  59  (Crosse). 


180  DISEASES  or  THE  PROSTATE. 

tills  and  amorplious  dust,  to  be  glued  togctlior  upon  a  nucleus  (kidney- 
stone),  or,  as  is  more  usual,  to  become  themselves  consolidated  by  the 
cement  of  mucoid  pus.  In  all  cases  of  enlarged  prostate,  where  there 
has  been  anj  considerable  amount  of  residuum,  stone  is  liable  to  form. 
Stone  is  the  logical  sequence  of  obstruction  to  urinary  outflow,  aided  by 
vesical  catarrh. 

A  stone,  or  several,  may  exist  under  these  circumstances  without 
giving  rise  to  any  symptom.  They  are  usually  smooth,  and  do  not 
scratch  or  irritate  the  floor  of  the  bladder  greatly,  nor  do  they  add 
much  to  the  already  existing  pain.  The  fibers  of  the  weakened  de- 
trusor can  net,  during  micturition,  force  a  stone  thus  formed  against 
the  sensitive  tissues  at  the  neck  of  the  bladder  and  produce  the  strik- 
ing symptoms  which  characterize  vesical  calculus  when  found  in  a 
licalthy  subject. 

Enlarged  prostate,  by  obstructing  the  free  outflow  of  urine  and 
damming  up  the  bladder,  tends  to  distend  the  cavity  of  the  latter, 
gradually  to  dilate  and  congest  the  ureters  and  pelves  of  the  kidneys, 
and  ultimately  to  excite  and  maintain  a  mild  inflammation  of  the  cor- 
tical and  medullary  structure  of  the  kidneys — which  exists,  as  a  rule, 
in  all  old  cases.  This  kidney  complication  is  easily  aggravated  by  any 
increase  in  the  bladder  congestion  ;  and  any  inflammation  of  the  blad- 
der is  liable  to  run  rapidly  up  the  ureters  and  further  congest  the 
kidneys,  bringing  on  symptoms  of  mild  uraemia,  with  more  or  less 
fever,  hot,  dry  skin,  loss  of  appetite,  and  a  particularly  dry  mouth 
and  tongue. 

In  these  cases  there  is  no  suppression  of  urine,  but,  on  the  con- 
trary, a  marked  polyuria,  as  a  rule,  sometimes  attended  by  a  trace  of 
sugar,  and  usually  showing  an  occasional  cast,  a  little  more  albumen 
than  the  pus  and  blood  in  the  sj)ecimen  will  account  for,  and  a  sp.  gr. 
of  about  1006  to  1016. 

Swelled  testicle  sometimes  accompanies  one  of  these  exacerbations 
of  inflammation,  but  more  usually  follows  the  introduction  of  an  in- 
strument. The  pressure  of  the  enlarged  prostate  occasions  also  con- 
gestion of  the  hsemorrhoidal  vessels,  while  the  violent  straining  not 
infrequently  brings  on  some  prolapse  of  the  rectum.  The  distress 
attending  this  group  of  morbid  changes  is  often  so  excessive  that  the 
patient's  life  becomes  a  burden  to  him. 

The  urine  is  that  of  catarrh  of  the  bladder,  and  this  catarrh,  the 
inevitable  accompaniment  of  prostatic  enlargement  at  some  ])eriod  of 
its  existence,  is  usually  limited  to  the  vicinity  of  the  neck.  Its  tend- 
ency is  to  involve  more  and  more  of  the  mucous  lining  of  the  body  of 
the  organ,  from  the  action  of  such  causes  as  cold,  over-acid  urine,  re- 
tention, etc.  The  urine  is  alkaline,  or,  even  if  faintly  acid,  it  has  an 
ammoniacal  odor,  and  often  a  fetid,  sickening  smell,  which  occasion- 
ally disappears.     When  the  urine  is  acid,  it  is  so  because  it  comes 


IIYPERTROrilY.  ISl 

down  strongly  acid  from  tlie  kidneys,  and  all  of  its  acidity  has  not 
been  neutralized  by  mingling  with  the  alkaline  residuum.  Whatever 
urine  has  been  alkalinized,  deposits  crystalline  and  amorphous  phos- 
phates, so  tiiat,  even  in  those  cases  where  the  urine  is  still  acid,  it  is 
murky,  cloudy,  filled  with  little  strings  and  clots  and  clouds  of  pus, 
and  with  gouts  of  ropy  muco-pus  (pus  agglutinated  and  made  trans- 
lucent by  ammonia).  A  few  blood-corpuscles  will  nearly  always  be 
found,  and  more  or  less  amorphous  urate  or  phosphate  (perhaps  both), 
with  (pretty  certainly)  crystals  of  triple  phosphate  entrapped  in  the 
"stringy  mucus,"  and,  possibly  at  the  same  time,  crystals  of  uric  acid, 
oxalate  of  lime,  or  other  varieties. 

The  above  detail  represents  the  course  of  changes  as  they  occur  in 
a  majority  of  instances  of  enlarged  prostate  ;  but  there  may  be  varia- 
tions. Thus  the  whole  prostate  may  be  enormously  enlarged  without 
any  median  posterior  hypertrophy,  and  consequently  without  any  ap- 
preciable diminution  in  the  caliber  of  the  urethra  or  obstruction  to 
the  outflow  of  urine.  In  these  cases  there  is  no  residuum.  The  pa- 
tient can  empty  his  bladder  entirely  ;  but  the  obstruction  to  the  return 
of  venous  blood  from  the  bladder-walls,  produced  by  pressure  of  the 
enlarged  prostate,  keeps  up  a  congestion  about  the  floor  and  neck  of 
the  organ  none  the  less.  Hence  the  symptom  known  as  irritability 
(constantly  recurring  desire  to  urinate),  is  pretty  sure  to  be  present, 
sometimes  to  an  intolerable  degree.  The  bladder  hypertrophies,  but, 
instead  of  dilating,  as  is  the  rule,  it  may  contract,  and,  as  there  is  lit- 
tle or  no  residuum,  sacculi  do  not  form  and  atony  does  not  come  on. 
This  condition  of  things,  unfortunately,  may  occur  even  where  there 
is  some  median  hypertrophy  and  a  small,  constant  residuum,  and  may 
even  be  found  occasionally  after  the  bladder  has  been  overstretched  by 
retention. 

This  is  always  to  be  regretted.  A  bladder  that  is  thoroughly 
atonied,  so  that  it  can  only  slowly  force  out  the  urine  through  a  cathe- 
ter, is  far  preferable.  Such  a  bladder  is  patient  and  uncomplaining, 
giving  its  possessor  but  little  uneasiness.  It  is  slow  to  take  on  inflam- 
mation, while  the  other  form  (where  full  contractile  power  remains, 
and  irritability  is  present)  is  usually  a  torment  to  its  owner  as  well  as 
to  the  surgeon.  The  bladder  contains  little  or  no  residuum,  the  urine 
continues  acid  and  only  slightly  murky  in  appearance  ;  but  the  calls 
to  urinate  are  incessant,  night  and  day,  and  the  bladder  can  not  be 
made  to  contain  more  than  an  ounce  or  two  of  urine  without  feeling 
as  if  it  were  splitting.  Thompson  speaks  of  an  old  gentleman  whose 
prostate  formed  an  ''  enormous  tumor  "  when  examined  by  the  rectum, 
yet  repeated  explorations  failed  to  find  a  drop  of  residual  urine.  The 
patient  was  tormented  by  an  incessant  desire  to  pass  water,  and  expe- 
rienced great  difficulty  in  the  act. 

Besides  the  two  conditions  already  alluded  to — namely,  dilatation 


182  DISEASES   OF   THE   PROSTATE. 

with  great  tolerance,  and  contraction  with  irritability — in  the  one  case 
the  patient  urinating  rarely,  unless  there  are  atony,  a  large  residuum, 
and  overflow  ;  in  the  other,  great  frequency  of  urination  being  always 
present — bqsidos  these  two,  there  is  one  other  condition,  possible  but 
rare,  namely,  true  incontinence.  Occasionally,  the  unsymmetrical 
development  of  the  prostatic  lobes  leads  to  a  slightly  patulous  condi- 
tion of  the  internal  orifice  of  the  urethra,  and  causes  true  inconti- 
nence, the  i)atient  being  unable  to  prevent  a  slight,  constant  dribbling 
away  of  the  urine.  In  nine  cases  out  of  ten  such  dribbling  is  the  re- 
sult of  overflow  ;  but  still  the  possibility  of  true  incontinence  must 
be  borne  in  mind.  A  distinction  between  the  two  is  easy.  Empty 
the  bladder  by  means  of  a  catheter  :  if  dribbling  recur  at  once,  we 
have  incontinence  ;  if  only  after  some  hours,  overflow. 

Course  of  Symptoms. — During  all  the  time  that  these  pathological 
changes  have  been  going  on,  a  period  of  many  months,  perhaps  years, 
ever  since  there  began  to  be  a  little  hyperremia  around  its  neck,  the 
bladder  has  been  getting  gradually  irritable.  The  patient  does  not 
readily  notice  it,  and  will  never  be  able  to  fix  a  precise  date  for  the  com- 
mencement of  his  troubles.  An  old  man  does  not  sleep  soundly  or  pay 
the  strictest  attention  to  the  performance  of  his  habitual  functions,  and 
he  so  gradually  acquires  the  habit  of  getting  up  a  little  earlier  than 
usual  in  the  morning  to  empty  his  bladder  that  he  pays  no  attention  to 
it.  Soon  he  finds  that  he  wakes  up  once  at  night,  ]icrhaps  twice,  with 
a  feeling  of  fullness  in  his  bladder.  He  passes  water,  and  goes  to  sleep 
again.  He  is  also  troubled  a  little  more  frequently  than  usual  in  the 
daytime,  but  he  looks  upon  it  as  a  condition  natural  to  advancing  life. 
He  has  learned  that  the  little  ills  of  the  flesh,  if  let  alone,  usually  regu- 
late themselves.  He  has  passed  water  without  trouble  for  fifty  or  sixty 
years,  and  he  thinks  that  he  ought  still  to  be  able  to  manage  it  without 
applying  to  his  surgeon.  He  shrinks  from  acknowledging  a  weakness, 
which  he  must  admit  to  be,  if  nothing  more,  a  symptom  of  advancing 
age,  and  so  he  goes  on  lulled  to  security,  making  water  at  intervals 
which  gradually  but  steadily  become  shorter,  getting  up  perhaps  every 
hour  at  night,  and  constantly  annoyed  by  a  faint,  obscure  sense  of 
weight  and  heaviness  about  the  lower  part  of  his  belly,  with,  perhaps,  a 
fullness  in  the  rectum,  and  a  dull  pain  behind  the  pubes.  The  bladder, 
now,  is  never  empty  ;  but  the  patient  does  not  know  it.  Only  an  excess 
above  a  certain  residuum  can  be  passed  off.  The  old  man  notices  also, 
perhaps,  that  he  has  to  wait  a  little  while  before  the  urine  begins  to 
flow,  that  the  stream  is  small,  and  is  not  projected  away  from  him  with 
any  force,  and  that,  perhaps,  a  part  of  the  urine  dribbles  down  perpen- 
dicularly from  the  meatus,  while  the  rest  flows  as  a  continuous  stream. 
Possibly  he  can  not  make  the  "coup  de  piston,"  the  final  s})asmodic 
clearing  of  the  urethra,  and  finds  that  a  few  drops  dribble  away  upon 
his  clothes  after  each  urinary  act.     He  does  not  experience  quite  as 


EYPERTROniY.  183 

much  ease  and  relief  as  usual  after  micturition  ;  but  this  has  come  on  so 
gradually  that  he  disregards  it.  He  finds,  however,  when  he  is  jolted 
through  the  streets  in  a  carriage  or  car,  that  his  calls  to  urinate  are 
even  more  frequent  than  usual. 

At  this  juncture  he  dines  out,  and  drinks  a  glass  or  two  of  wine  more 
than  usual,  or  he  neglects  a  call  to  urinate,  or  gets  a  wetting,  or  his  feet 
and  legs  get  cliilled  (the  latter  a  very  common  cause  of  trouble),  and 
suddenly  he  finds  that  he  can  not  pass  water  at  all.  After  vainly  try- 
ing at  intervals  for  a  number  of  hours,  if  he  does  not  seek  surgical  relief, 
at  last  the  urine  will  begin  to  dribble  away  from  him.  The  bladder  has 
been  distended  to  its  utmost,  the  mouth  of  the  urethra  has  been  dragged 
open  slightly,  and  the  excess  of  urine  trickles  involuntarily  away.  This 
is  overflow  and  not  incontinence.  Meantime  the  patient  has  been  suf- 
fering the  torments  known  only  to  those  who  have  had  retention,  and 
he  hails  the  overflow  with  delight,  believing  that  his  sufferings  are 
about  to  cease.  The  hope  is  vain.  The  congestion  of  the  bladder  neck, 
brought  on  by  the  use  of  liquor,  or  by  the  chilling,  and  which,  added 
to  the  already  large  prostate,  has  swollen  it  sufficiently  to  shut  up  the 
urethra  entirely,  subsides  shortly.  G-ravity,  and  the  contractions  of  the 
abdominal  muscles  and  of  the  diaphragm,  are  together  able  to  dispose 
of  a  certain  excess  of  urine,  which  the  overstretched  bladder,  now  in  a 
condition  of  atony,  is  unable  to  void.  The  patient,  perhaps,  recovers 
from  his  overflow,  but  his  residuum  is  greatly  in  excess  of  what  it  was 
before  his  attack  of  retention,  his  calls  to  urinate  are  more  frequent,  he 
is  disturbed  more  often  at  night.  All  his  former  feelings  of  uneasiness 
and  pain  about  the  hypogastrium  and  perinseum  are  increased ;  digestion 
is  impaired  ;  the  appetite  fails  ;  and,  worn  out  by  loss  of  sleep,  inability 
to  eat,  and  constant  uneasiness  amounting  to  actual  pain,  the  sufferer 
runs  down,  aging  rapidly,  and  becoming  fretful  and  irritable,  losing 
all  interest  in  business,  and  nearly  all  pleasure  in  life. 

A  second  and  third  retention  come  on  and  aggravate  the  situation. 
Perhaps  a  stone  is  forming,  as  is  always  apt  to  be  the  case.  The  blad- 
der may  ulcerate  and  pericystitis  ensue,  and  death  finally  close  the 
scene,  the  most  common  mode  of  death  being  by  ursemia,  induced  by 
a  little  extra  congestion  of  the  secreting  portion  of  the  kidneys. 

The  foregoing  clinical  history  is  that  of  a  type  case.  It  may  be 
variously  modified,  according  to  the  pathological  condition  of  the 
bladder  and  prostate  ;  there  may  never  be  any  retention  ;  on  the  con- 
trary, there  may  be  constant  true  incontinence,  or  the  bladder  may 
take  on  acute  inflammation,  after  an  overdistention,  with  retention, 
and  carry  oS.  the  patient  with  acute  febrile  symptoms.  Pyelitis  or 
perinephritis  may  come  in  as  complications,  and  quickly  close  the 
scene,  or  certainly  precipitate  the  catastrophe. 


184  DISEASES  OF  THE  PROSTATE. 


CHAPTER  X. 

DISEASES  OF  THE  PROSTATE. 

Hypertrophy  (continiiedV — Diagnosis;  Descrijition  of  Instruments  and  Mano'iivres  employed  in 
their  Use.— Exaniiniition  of  Patient. — Mctliods  of  retaining  Catheters  in  the  Hladder.— Metliods 
of  deciding  upon  the  Charaeter  and  Extent  of  Prostatic  Deformity  as  affecting  the  Course  of  the 
Urethra.— Treatment.— Treatment  of  Complications.— Internal  Remedies  in  Prostatic  Disease- 
Natural  Mode  of  Death  due  to  Ilypertrophied  Prostate. 

Diagnosis. — When  a  patient  of  over  fifty  comes  to  seek  relief  for 
frequent  micturition,  suspicion  falls  at  once  upon  the  prostate.  It  is 
rare  that  stricture  causes  trouble  for  the  first  time  so  late  in  life  ;  more- 
over, witli  enlarged  prostate,  the  inconvenience  will,  as  a  rule,  have 
been  first  noticed  at  night — the  reverse  of  what  is  observed  in  stricture. 
As  the  first  step  in  the  examination,  the  patient  should  be  placed  upon 
his  back,  with  the  knees  elevated  and  abdomen  relaxed,  and  a  digital 
examination  made  through  the  rectum.  B}'  this  means  alone  general 
prostatic  hypertrophy  can  always  be  demonstrated.  In  ])lace  of  the 
soft,  chestnut-like  body,  hardly  recognizable  except  by  the  skilled 
touch,  the  finger  will  encounter  a  rounded,  dense  mass,  smooth  and 
symmetrica],  or  variously  distorted  and  nodulated.  The  median  fis- 
sure between  the  lobes  may  be  more  than  usually  perceptible,  or  may 
be  wholly  obliterated  ;  while  the  finger  passed  up  on  either  side,  be- 
tween the  prostate  and  the  walls  of  the  pelvis,  recognizes  a  deepening 
of  the  sulcus,  and  any  undue  prominence  in  size  of  one  or  the  other 
lobe.  Forcing  the  finger  well  up  the  rectum,  it  may  be  impossible  to 
hook  the  last  phalanx  above  the  posterior  margin  of  the  enlarged  pros- 
tate, while  the  seminal  vesicles  can  usually  be  made  out  on  cither  side, 
partly  imbedded  in  the  general  hypertrophy. 

Perhaps  rectal  examination  may  reveal  none  of  these  positive  evi- 
dences of  enlargement,  median  hypertrophy  existing  none  the  less.  In 
such  a  case  the  finger  readily  detects  the  bladder,  if  it  be  distended, 
beyond  the  prostate  ;  the  latter  apparently  not  at  all  or  but  little 
larger  than  normal.  Pressure  through  the  rectum  upon  an  enlarged 
prostate  does  not  cause  pain,  unless  there  be  some  inflammation  about 
the  neck  of  the  bladder.  It  often,  however,  proA'okes  a  desire  to  uri- 
nate. 

The  next  step  in  the  examination  is  to  make  out  the  condition  of 
the  bladder  by  palpating  and  percussing  the  hypogastrium.  Usually 
this  method  does  not  throw  any  light  upon  the  condition  of  the  pros- 
tate, unless  it  is  exceedingly  large,  when  pressure  upon  it  tlirough  the 
rectum  may  be  recognized  by  the  hand  upon  the  hypogastrium.  The 
same  occurs  in  those  rare  cases  of  excessive  hypertrophy  of  the  bladder- 


IIYrEIlTROPIIY.  liNJ5 

walls  with  contraction  of  its  cavity  (concentric  hypertrophy).  As  a 
rule,  hypogastric  palpation  only  reveals  the  fact  that  pressure  above 
the  pubes  excites  a  desire  to  urinate — from  transmission  of  the  force 
to  the  sensitive  neck  of  the  bladder.  Sometimes,  however,  an  oval 
tumor  is  found,  as  large  as  a  child's  head,  filling  up  the  lower  part  of 
the  belly,  perhaps  as  high  as  the  umbilicus,  flat  on  percussion,  and 
causing  a  desire  to  urinate  when  pressure  is  made  upon  it.  This 
tumor,  formed  by  the  overdistended  bladder,,  may  often  be  plainly 
seen,  but  the  patient  is  usually  unconscious  of  its  existence.  If  the 
finger  in  the  rectum  can  reach  beyond  the  posterior  border  of  the  pros- 
tate, fluctuation  can  be  felt  between  it  and  the  other  hand  pressed 
upon  the  hypogastrium. 

The  patient  is  now  asked  to  stand  up  and  to  pass  water  into  a  glass 
vessel.  A  little  gleety  discharge  may  be  often  fouiid  at  the  meatus, 
originating  from  the  congested  surface  of  the  prostatic  urethra.  Oc- 
casionally, if  questioned,  the  patient  will  confess  that  he  is  troubled 
with  frequent  erections,  the  cause  of  which  lies  in  this  same  congestion. 
Sometimes,  on  the  other  hand,  erections  are  absent. 

As  the  urine  is  flowing  off,  it  will  be  noticed  that  it  commences 
tardily,  and  in  a  small  stream,  which  gradually  enlarges.  There  is 
very  little  force  to  the  flow.  There  may  be  two  streams,  the  one  pro- 
jected, and  the  other  dribbling  perpendicularly  from  the  meatus,  in- 
dicating an  obstacle  at  the  outlet  of  the  bladder  to  the  escape  of  urine. 
If  there  is  retention,  the  urine  will  not  flow  at  all,  or  comes  away  only 
by  drops.  While  the  stream  is  flowing,  if  the  patient  be  requested  to 
strain,  instead  of  becoming  larger  or  flowing  with  greater  force,  the 
stream  may  be  diminished  in  size  and  power.  Under  these  circum- 
stances a  ball-and-socket  arrangement,  or  some  valvular  condition  of 
the  overgrowth,  may  be  predicated,  which,  when  acted  upon  by  the 
pressure  of  the  abdominal  muscles  through  the  mass  of  accumulated 
urine,  tends  still  further  to  occlude  the  internal  urethral  orifice,  so 
that  the  stream  flows  fastest  when  the  least  effort  is  made.  If  the 
bladder  be  inflamed,  there  may  be  severe  tenesmus  and  pain  during 
the  attempt  to  urinate,  and  the  rectum  may  protrude  or  fa?ces  be 
passed  during  the  act.  Hernia  may  be  occasioned  by  the  violent 
straining.  At  the  end  of  urination  the  stream  gradually  dribbles 
away  into  drops,  and  often  the  final  jet  or  "coup  de  piston  "'  is  want- 
ing, although  the  latter  may  be  perfect  or  even  exaggerated. 

If  the  urine  which  has  been  voided  be  now  held  up  to  the  light,  it 
will  be  found  to  be  cloudy,  troubled,  perhaps  bloody,  often  ammoniacal, 
and  to  contain  white  flocculi  of  pus,  or  perhaps  gouts  of  stringy  muco- 
pus,  or  again  it  may  be  perfectly  clear.  The  condition  of  the  urine 
indicates  the  amount  of  cystitis  present,  while  its  quantity  (in  residu- 
um) and  the  force  of  its  flow,  after  the  catheter  has  been  introduced, 
allow  an  estimate  of  the  degree  of  atony.     There  may  be  considerable 


186 


DISEASES   OF   THE   PROSTATE. 


irritability,  witli  little  or  no  cystitis,  and  in  such  cases  the  urine  is 
nearly  or  quite  clear,  generally  strongly  acid,  and  of  high  specific 
gi'avity.  Usually  there  is  more  or  less  pus  present,  indicating  cystitis, 
and,  when  the  latter  is  of  a  high  grade,  the  fluid  is  often  ammoniacal, 
or  has  a  fetid  odor  of  decomposition,  is  tilled  with  pus,  more  or  less 
blood,  fluid  or  in  clots,  and  stringy  muco-i)us,  which  is  often  gritty 
from  containing  large  quantities  of  triple-phosphate  crystals. 

AVhen  the  patient  has  voided  all  the  water  lie  can,  he  is  again 
l)laced  upon  his  back,  and  a  full-sized  silver  catheter  of  short  curve 
passed  gently  down  toward  the  bladder.  The  instrument  Avill  usually 
go  smoothly  along  (perhaps  halting  for  a  little  coaxing  at  the  triangu- 
lar ligament)  until  it  has  reached  a  depth  of  from  six  to  eight  or  more 
inches,  when  it  will  stop.  On  no  account  should  the  least  force  be 
employed.  A  finger  is  now  again  introduced  into  the  rectum  to  feel 
whether  the  instrument  is  in  a  false  passage,  which  may  have  been 
made  in  some  previous  attempt  at  catheterization.     If  it  is  found  to 

be  in  the  canal  and  in  the  medi- 
an line,  the  finger  can  readily 
appreciate  the  approximate  in- 
crease in  thickness  of  that  seg- 
ment of  the  prostate  lying  be- 
tween the  instrument  and  the 
rectum ;  and  a  diagnosis  of  ob- 
struction in  the  floor  of  the  ure- 
thra at  the  neck  of  the  bladder 
is  established. 

In  examining  a  patient  for 
the  first  time,  it  should  never  be 
lost  sight  of  that  we  are  dealing 
with  an  old  man  whose  urinary 
passages  are  in  a  more  or  less 
irritable  condition,  and  probably 
unused  to  local  disturbance.  Any 
examination  whicli  is  at  all  rough 
or  too  prolonged  is  j^retty  sure 
to  be  followed  by  some  aggrava- 
tion of  the  sym])toms,  and,  un- 
less the  condition  be  urgent  (retention),  it  is  often  advisable  to  make 
only  a  partial  exploration  at  the  first  sitting,  leaving  the  rest  for  an- 
other day.  If  made  worse  by  his  first  examination,  the  old  man 
becomes  far  less  docile  for  future  management.  If,  however,  there 
is  retention  with  or  without  overflow,  it  becomes  the  surgeon's  duty 
to  make  judicious  use  of  all  available  means  to  enter  the  bladder  with 
a  catheter. 

The  next  step  in  the  examination  is  to  determine  the  nature  of  the 


Fig.  CO  {T/wtJipson). 


IIYPERTROPHY. 


187 


obstruction  in  the  iTrethra,  and  some  instrument  must  be  found  which 
will  enter  the  bladder.  Unless  the  "third  lobe"  rise  very  abruptly 
from  the  floor  of  the  urethra,  the  bladder  may  be  entered  by  a  silver 
catheter  with  an  extra  long  curve.  Such  an  instrument  should  be  of 
large  size.  The  surgeon  should  be  provided  with  several  of  them  of 
different  sizes  (from  No.  15  to  24),  and  with  varying  curves  (Fig.  60). 
One  of  these  instruments  will  usually  slip  into  the  bladder,  a  flow  of 
urine  announcing  the  success  of  the  operation. 

Generally  the  amount  of  residual  urine  is  small.  The  degree  of 
irritability  is  not  proportionate  to  the  amount  of  urine  which  can  not 
be  voluntarily  passed  ;  indeed,  it  may  be  greatest  where  the  residuum 
is  at  a  minimum.  It  is  always  a  favorable  sign  for  prognosis,  as  far 
as  the  future  comfort  of  the  patient  is  concerned,  to  find  a  copious 
residuum  upon  the  introduction  of  the  catheter.  Such  cases  are 
always  more  easily  managed  than  others,  provided  only  the  patient 
can  be  taught  to  introduce  a  catheter  for  himself,  since,  by  keeping 
his  bladder  from  overfilling,  he  can  avoid  his  most  disagreeable  symp- 
tom— continually  recurring  desire  to  urinate.  Should  the  silver  in- 
strument fail  to  enter  the  bladder,  a  small  conical  olivary  French 
catheter,  with  a  slender  neck  and  a  long  fixed  curve  in  its  woven 
structure,  designed  to  keep  its  point  in  contact  with  the  roof  of  the 
urethra,  will  sometimes  override  the  obstacle  and  effect  an  easy 
entrance. 

Failing  in  this,  Thompson's  method  may  be  ^ 
employed.  A  medium,  smooth,  blunt  English 
catheter  is  selected,  its  stylet  removed,  and 
itself  bent  into  an  exaggerated  curve,  the  last 
inch  of  the  curve  being  more  accentuated  than 
the  rest.  When  the  instrument  has  been  shaped 
(Fig.  61),  it  is  held  for  a  moment  in  cold  water, 
which  causes  it  to  retain  the  curve  it  has  re- 
ceived until  it  again  becomes  warm.  The  in- 
strument so  curved  is  oiled,  and,  without  a 
stylet,  rapidly  introduced,  so  as  to  allow  the 
heat  of  the  urethra  to  act  upon  it  as  little  as 
possible.  It  reaches  the  floor  of  the  prostatic 
urethra  before  the  point  has  lost  its  exaggerated 
curve,  and  this  point,  following  the  roof  instead  fig.  6i  (Thompson). 

of  the  floor  of  the  canal,  readily  surmounts  any 

median  hypertrophy  and  passes  over  the  "  third  lobe  "  into  the  bladder. 
Another  excellent  method  of  overriding  median  hypertrophy  with  an 
English  catheter  is  to  introduce  the  latter  armed  with  a  stylet  of 
exaggerated  curve.  When  an  obstacle  is  encountered,  the  stylet  is 
slightly  withdrawn.  This  manoeuvi'e  causes  the  beak  of  the  catheter 
to  tilt  upward  sufficiently  to  surmount  the  obstruction. 


188 


DISEASES   OF   THE   PROSTATE. 


Another  instrument  devised  by  Frencli  ingenuity,  and  capable  of 
rendering  valuable  serviee  where  perhaps  no  other  catheter  will  pass, 
is  a  catheter  known  by  the  name  of  its  inventor,  Mercier.  It  is  an . 
elbowed  instrument,  having  a  fixed  angle  (Fig.  G2,  A),  or  two  angles 
(Fig.  G3,  B),  in  the  woven  material  of  which  it  is  constructed.  The 
English  now  make  similar  instruments,  usually  colored  brown,  some- 


0.   TIEMANN  \  CO. 


Fig.  62. 

times  black.  They  are  generally  too  stiff  and  their  angle  is  too  obtuse  ; 
consequently,  though  more  durable,  they  are  not  so  useful  in  difficult 
cases  as  the  black  French  instrument.  This  catheter  (similar  instru- 
ments, with  one  or  two  angles,  are  also  made  of  metal)  is  avowedly 
constructed  to  override  obstructions  in  the  floor  of  the  urethra,  such 
as  posterior  median  hypertrophy.  The  point  follows  the  roof  of  the 
canal  or  strikes  any  obstacle  upon  its  inclined  sur- 
face, and  at  an  angle  which  allows  the  instrument 
to  ride  over  the  obstruction.  For  difficult  cases 
these  catheters  are  invaluable. 

The  instruments  already  described  suffice  for 
general  enlargement  and  for  cases  of  "third  lobe," 
but  occasionally  the  canal  may  be  so  deviated  by 
irregular  lateral  overgrowths  that  even  these  instru- 
ments fail  to  effect  an  entrance.  For  such  cases 
there  are  several  instruments  left.  Philliiis's  cath- 
"M  tt  eter,  open  at  both  ends,  introduced  over  a  two-foot 

^/#  y^"^  guide,  must  not  be  forgotten.  The  red,  soft-rub- 
ber catheter  (Fig.  63)  is  an  instrument  of  superior 
value.  It  is  introduced  without  a  stylet,  and  will 
sometimes  follow  the  sinuous  windings  of  a  prostatic 
urethra  where  all  other  instruments  fail.  There  are 
three  varieties  in  the  market,  the  prototype  of  the 
group,  the  old  French,  rough,  red  rubber  catheter 
known  by  Nelaton's  name,  having  disappeared.  Of 
the  three  varieties,  the  English — now  made  with  bev- 
eled eye — has  the  smoothest  finish.  The  American 
instruments,  called  the  velvet-eyed  catheter  and  the  Goodyear,  are 
nearly  as  smooth.  These  catheters  grow  large  and  soft  by  use,  and 
grow  brittle  sometimes  by  age — the  former  peculiarity  makes  them 
difficult  to  use  on  account  of  their  limpness  ;  the  latter  makes  them 
sometimes  dangerous,  for  they  crack,  and  pieces  may  break  off  and 


Fig.  C3. 


nYPERTRQPIIY. 


189 


remain  in  the  bladder.  I  have  removed  such  pieces  on  several  occa- 
sions. "When  the  soft-rubber  catheter  is  too  limp  to  be  used,  it  may 
be  rendered  more  rigid,  without  having  its  flexibility  inter- 
fered with,  by  the  use  of  Otis's  stylet  (Fig.  G-i),  or  one  that  | 
I  have  devised  for  a  similar  purpose  made  of  the  cable  of  the 
dental  engine  (Fig.  65).  A  new  catheter  has  appeared  of  late 
in  all  shapes — open-ended,  olivary,  blunt,  curved  Mercier,  etc. 
— made  of  woven  silk,  and  covered  with  an  elastic 
varnish  of  high  finish.  This  is  an  admirable  instru- 
ment, possessing  all  the  advantages  of  the  rubber 
catheter  and  considerably  more  rigidity,  so  that  in 
some  cases  it  is  much  easier  of  introduction.  Its  stiff- 
ness, however,  is  in  some  cases  a  disadvantage,  and 
it  wears  out,  like  all  woven  catheters,  by  blistering — 
a  serious  defect.  Instruments  of  soft  rubber  may  be 
worn  in  the  bladder  for  a  considerable  length  of  time 
without  (in  many  cases)  producing  much  uneasiness 
or  becoming  incrusted  by  urinary  salts,  if  the  bladder 
be  washed  out  with  warm  water  pretty  regularly. 
Self-retaining  catheters  have  not  proved  successful, 
and  their  use  has  been  abandoned.  To  tie  a  catheter 
in  the  urethra,  the  simplest  method  is  to  tie  about  it 
close  to  the  meatus  two  soft  strings.  This  doubled 
ligature  is  then  knotted  on  each  side  at  the  level  of 
the  corona,  and  tied  loosely  under  the  corona  if  the 
latter  is  prominent ;  otherwise  the  knotting  is  done  a 
little  lower  down,  and  the  penis  and  ligatures  encircled 
with  a  double  roll  of  narrow  rubber  plaster.  After 
the  plaster  has  adhered  firmly,  it  should  be  cut  in  the 
long  axis  of  the  penis,  to  allow  erection.  Or,  finally, 
the  ligatures  may  be  knotted  to  the  hairs  on  the 
pubes,  as  Thompson  advises.  The  French  catheter- 
holder  of  soft  rubber  gets  out  of  order,  and  is  not 
better  than  the  soft  strings.  The  Squire  jointed  cath- 
eter has  been  well  spoken  of.  I  have  never  been  able 
to  make  it  pass  when  other  instruments  failed.  It  is 
made  of  silver  segments  of  small  size,  not  united  together,  but  held  in 
contact  by  a  little  flexible  chain,  running  through  the  hollow  of  the 
catheter,  and  attached  firmly  to  the  last  segment,  which  contains  the 
eye  (Fig.  66).  The  central  chain  terminates  in  a  wire,  which  appears 
at  the  mouth  of  the  catheter  in  the  shape  of  a  screw,  furnished  with  a 
circular  nut.  By  loosening  the  nut  and  pushing  down  the  wire,  all  the 
segments  making  up  the  end  of  the  instrument  fall  apart ;  by  tighten- 
ing it  they  are  stiffened  up  and  brought  into  j^lace,  being  left  in  a  con- 
dition more  or  less  flexible,  according  to  the  tension  of  the  central 


Fig.  64.      Fig.  65. 


190 


DISEASES   OF   THE   TROSTATE. 


chain.     This  instrament,  pushed  down  into  a  tortuous  canal,  is  capable 
of  assuming  any  curve,  and  following  the  windings  of  the  passage.     It 


Fig.  66. 


is  not  devoid  of  danger,  because  the  chain  holding  the  joints  together 
has  been  known  to  break,  leaving  the  metallic  segments  in  the  bladder. 


YVA_m,U,U>^J,..U^ 


;;:^_S.  TI£MANN  (f  CO 


3 


curve, 
truded 


Fig.  or. 

A  similar  and  perhaps  better  instrument  is  the  metallic  catheter 
known  as  Gross's  catheter,  having  a  sort  of  spiral  end  (Fig.  67). 
It  has  proved  serviceable  in  some  cases.  The  objection  to  it  is 
the  temptation  to  employ  force  in  its  manipulation. 

Another  ingenious  instrument  of  Mercier's  may  be  useful. 

It  is  designed  to  avoid  false  passages.     A  silver  tube,  of  long 

is  furnished  with  a  central  woven  catheter,  which  may  be  pro- 

and  pushed  on  through  an  aperture  in  the  concavity  of  the 


Fig.  68. 

instrument  near  its  point  (Fig.  68).  The  solid  beak  of  the  instru- 
ment enters  the  false  passage,  the  soft  catheter  is  protruded,  and 
passes  onward  in  the  urethra  into  the  bladder. 

Methods  of  estimating  the  Size  and  Character  of  Prostatic 
Overgrowth. — It  is  sometimes  desirable,  for  accuracy  of  diagnosis,  or 
other  object,  to  get  an  approximate  idea  of  the  exact  situation  and 
size  of  the  overgrowtb,  together  with  the  direction  and  amount  of  the 
deviation  of  the  pro.-tatic  urethra,  perhaps  for  purposes  of  rough  com- 
parison from  time  to  time,  to  decide  what  advance  is  being  made  by 
the  disease.  A  good  deal  of  information,  in  a  general  way,  may  be 
gained  on  these  points.  In  introducing  the  silver  catheter  of  long 
curve,  if  the  prostatic  urethra  be  deviated  to  the  right  or  left  by  the 
undue  development  of  either  lobe,  the  point  of  the  in.^trumcnt  will  be 
coiTespondingly  deviated,  and  the  degree  may  be  roughly  estimated 


HYPERTROPHY. 


101 


by  noticing  the  movements  communicated  to  the  handle.  T])e  increase 
in  the  antero-posterior  diameter  of  the  prostate  may  be  rudely  calcu- 
lated with  the  same  instrument  by  noticing  the  depth  to  which  tlic 
eye  has  to  penetrate  before  it  finds  water — instead  of  seven  or  eight 
inches,  perhaps  ten,  eleven,  or  more.  In  studying  out  the  form  of 
overgrowth  at  the  neck  of  the  bladder,  all  the  information  necessary 
may  be  obtained  with  a  short-beaked,  solid  sound  of  the 
curve  known  as  Leroy  d'Etiolles's,  or  Mercier's,  or  with 
the  similarly  shaped  metallic  instrument  known'as  Thomp- 
son's stone-searcher  (Fig.  69),  the  advantage  of  the  latter 
being  that  it  is  a  catheter  as  well  as  a  searcher,  and  that, 
after  the  introduction,  the  bladder  may  be  emptied,  in- 
jected full,  or  distended  to  any  desired  extent,  so  as  to 
facilitate  examination,  all  of  this  without  removing  the 
instrument.  The  bladder  should  always  contain  a  few 
ounces  of  fluid  when  this  instrument  is  used.  There  is 
rarely  any  difficulty  in  introducing  it  through  an  enlarged 
prostate.  Like  Mercier's  catheter,  it  is  peculiarly  adapted 
to  glide  over  obstructions  in  the  floor  of  the  urethra,  and 
this  is  the  variety  of  obstruction  which  exists  most  fre- 
quently, and  which  most  often  o|3poses  an  obstacle  to  the 
entrance  of  rigid  instruments,  or  those  of  ordinary  curve. 

In  examining  an  old  case  of  atonied  bladder,  with  en- 
larged prostate,  for  stone  (and  this  examination  should 
always  be  made  whether  there  are  symptoms  of  stone  or 
not),  Thompson's  searcher  is  the  best  instrument  to  use, 
and  during  the  search  the  condition  of  the  internal  orifice 
of  the  urethra  should  be  examined.  In  introducing  the 
instrument,  if  it  is  necessary  to  depress  the  handle  greatly, 
in  order  to  get  through  the  last  part  of  the  prostatic  ure- 
thra, it  is  because  the  beak  of  the  searcher  must  rise 
gradually  over  a  posterior  median  enlargement.  If  the 
beak  seems  to  strike  abruptly  against  a  bulkhead,  and  on 
a  little  manipulation,  perhaps,  to  slip,  with  a  start,  sud- 
denly into  the  bladder,  the  obstruction  is  probably  a  bar. 
When  the  beak  is  in  the  bladder,  it  is  retracted  until  it 
hooks  the  upper  margin  of  the  urethral  orifice.  The  shaft 
is  now  held  nearly  horizontally,  and  the  instrument  rotated.  (The 
bladder  must  contain  a  few  ounces  of  fluid.)  If  the  prostate  be 
healthy,  or  the  obstruction  a  bar,  this  rotation  can  be  performed  with- 
out sensibly  altering  the  direction  of  the  shaft  of  the  instrument. 
If  there  be  a  tumor  jutting  out  anywhere  from  the  prostate  (posterior, 
median,  or  other  enlargement),  the  beak  becomes  arrested,  and  the 
direction  of  the  handle  has  to  be  changed  in  order  to  make  it  over- 
ride the  obstacle.     Such  deviation  will  give  the  approximate  position 


Fig, 


192 


DISE.iSES  OF  THE  PROSTATE. 


Fig.  rO. 


and  size  of  tlie  outgrowtli.  Finall}',  in  withdrawing  tlie  instrument-., 
if  the  prostate  be  healthy,  it  may  be  retracted  easily  with  the  beak 
downward,  while  it  will  hook  against  any  posterior  median  enlarge- 
ment (Fig,.  TO).     AVith  the  searcher  the  liypertrophied  trabeculfe  of 

mnscuUir  tissue  of  the 
bladder  may  be  also  rec- 
ognized, and  their  size 
and  number  roughly  es- 
timated. 

Treatment. —  In  the 
present  state  of  our 
knowledge,  hypertro])hy 
of  the  prostate  is  not 
curable  by  any  means 
that  have  yet  been  used 
—  by  iodine,  bromine, 
electricity,  or  pressure. 
The  advocates  of  these 
and  other  methods  have  failed  to  establish  their  claims.  Inflammatory 
increase  in  size  may  be  successfully  combated,  hypertrophic  aj^parently 
not.  But  still  a  vast  deal  of  comfort  may  be  afforded  to  patients  ; 
they  can  always  be  greatly  relieved,  sometimes  cured,  that  is,  freed 
from  every  subjective  symptom.  It  is  only  necessary  to  remember 
that  hypertrophy  of  the  jjrostate  is  a  mechanical  malady,  obstructive 
in  its  character,  in  order  to  appreciate  at  once  the  great  object  and  end 
of  treatment,  namely,  to  overcome  by  art  the  obstruction  erected  by 
Nature  to  the  free  outflow  of  urine.  The  catheter  is  the  natural  spe- 
cific for  enlarged  prostate,  just  as  the  steel  sound  is  for  stricture  of  the 
deep  urethra.  The  catheter  is  no  novelty  in  surgery.  A  need  for  its 
use  has  been  recognized  for  ages,  probably  in  just  these  cases  of  old 
men  with  enlarged  prostate.  Very  good  specimens  of  lead,  copper,  and 
bronze  catheters  (of  long  curve)  have  been  found  among  the  ruins  of 
Pompeii.  But,  to  be  effective,  the  use  of  the  catlicter  must  be  intel- 
ligent, and  other  means  must  assist  its  employment,  while,  in  very 
rare  instances,  where  there  is  no  residual  urine,  it  is  of  little  or  no 
service. 

The  best  method,  I  believe,  to  go  about  relieving  the  symptoms  of 
]n'ostatic  hypertrophy,  is  to  attempt  to  blunt  the  sensitiA'Cness  of  the 
deep  urethra  by  the  passage  of  soft  bougies  or  the  steel  sound  at  appro- 
priate intervals,  and  to  overcome  muscular  spasm  of  the  deep  urethra, 
to  which  nearly  all  the  symptoms  are  due  in  many  cases  of  jorostatic 
enlargement.  I  think  that  the  common  olivary  French  bougies,  or  in 
many  cases  the  long-curved  steel  sound  is  an  appropriate  instrument 
for  this  purpose.  Reginald  Harrison  has  devised  a  soft  bougie  with  a 
long  oval  bulb  at  its  extremity  (Fig.  71),  which  he  deems  especially 


HYPERTROPHY— TREATMENT. 


193 


suitable  and  appropriate  for  this  purpose,  ascribing  some  of  the  value 
of  the  instrument  to  the  fact  that  its  shape  allows  it  to  dilate  the  neck 
of  the  bladder  on  its  way  out  as  well  as  on  its  way  in.  I  have  found 
in  many  instances  most  positive  advantage  in  overcoming  irritability, 


Fig.  71. 

spasm,  and  cystitis  of  the  neck  of  the  bladder,  in  cases  of  enlarged 
prostate,  in  the  use  of  deep  urethral  instillations  of  the  nitrate  of 
silver  with  the  deep  urethral  syringe  (p.  78),  throwing  about  three 
drops  of  a  solution  of  a  strength  varying  from  gr.  ss  in  the  |  j  up  to 
gr.  X  or  more  in  the  3  j,  into  the  membranous  urethra,  at  intervals 
of  from  two  or  three  days  up  to  a  week  or  ten  days.*  The  method  is 
not  suitable  to  all  cases.  Where  it  agrees  it  gives  comfort,  but  does 
not  cure,  and  takes  rank  with  the  bougie  and  sound,  but  is  far  better 
than  either  in  appropriate  cases. 

Next  in  value  comes  systematic  drilling  in  the  use  of  the  catheter. 
If  the  residual  urine  is  small  in  amount,  and  the  fluid  clear,  the  cath- 
eter sometimes  gives  no  relief,  and  may  be  dispensed  with.  When 
there  is  considerable  atony  the  bladder  must  be  emptied.  Here  the 
utmost  care  must  be  employed,  for  many  an  old  man  has  been  brought 
to  his  death  directly  by  the  zeal  of  his  medical  attendant,  who  has 
been  too  precipitate  in  managing  an  atonied  bladder  with  a  catheter. 
The  best  care  and  the  nicest  attention  often  fail  to  avert  lighting 
up  cystitis  at  the  commencement  of  catheter  life,  but  proper  care 
and  attention  will  save  a  certain  percentage  of  cases,  and  many  valu- 
able lives. 

To  test  for  residual  urine  the  patient  stands  and  urinates.  Then, 
if  a  catheter  is  to  be  used  for  the  first  time,  a  clean,  disinfected  rubber 
instrument  (or  any  other)  is  selected,  and  washed  in  very  hot  water. 
This  I  believe  to  be  as  good  as  any  antiseptic  liquid.  The  catheter 
selected  is  gently  passed,  the  patient  being  erect  or  prostrate,  as  the 
surgeon  may  prefer,  and  the  urine  drawn  off.  If  the  patient  is  nerv- 
ous or  in  any  case  of  doubt,  the  recumbent  posture  and  rubber  catheter 

*  Consult  a  paper  on  this  subject  by  E.  L.  Keyes,  "New  York  Medical  Record,"  May 

28,  188Y. 

13 


194  DISEASES   OF  THE   PROSTATE. 

are  to  be  preferred.  If  the  bladder  is  considerably  distended,  all  the 
urine  should  not  be  drawn  off  at  the  first  sitting  ;  a  half  or  a  quarter  of 
it  should  be  left  in.  Even  when  the  residuum  is  comparatively  small, 
I  thinl-  it  better  to  leave  a  little  hot  borax  water  in  the  bladder  after 
drawing  off  the  urine.  Some  of  this — a  dessertspoonful  to  the  i)int — 
may  be  at  hand  in  a  bag-syringe.  It  is  not  well  to  leave  the  bladder 
empty  after  it  has  long  been  distended.  This  is  particularly  true  when 
the  bladder  has  habitually  been  considerably  overdistended — beyond  a 
])int.  Nor  is  it  well  ever  to  empty  one  of  these  largely  overdistended 
bladders  in  the  erect  posture.  Death  has  been  known  to  follow  im- 
mediately upon  the  entire  withdrawal  of  the  contents  of  such  a  blad- 
der, faintness  is  not  uncommon,  and  cystitis  almost  inevitable. 

After  the  first  passage  of  the  catheter  the  patient  should  remain 
warm  and  quiet,  but  not  necessarily  in  bed,  for  some  hours,  preferably 
for  an  entire  day.  After  a  few  days  the  process  may  be  repeated,  and 
presently  the  bladder  may  be  entirely  emptied  and  left  empty. 

The  most  common  form  of  the  so-called  catheter-fever  is  that  which 
comes  on  four  or  five  days,  perhaps  a  week,  after  the  first  introduction 
of  the  catheter,  when  the  patient  will  become  chilly,  ill  at  ease,  the 
urine  faintly  brothy  from  mucus  and  pus,  containing  bacteria.  This 
condition  persists,  and  becomes  aggravated  more  or  less  by  symptoms 
of  cystitis,  which  may  run  high,  with  blood  in  the  urine  and  great 
tenesmus.  Chills  may  recur.  The  temperature,  usually  high,  is 
sometimes  subnormal  from  the  beginning.  Pyelitis  may  come  on, 
and  multiple  bacterial  abscess  in  the  kidney,  and  the  patient  may  die 
in  four,  six,  eight  weeks — perhaps  even  later — after  the  first  intro- 
duction of  the  catheter,  which  has  been  the  direct  occasion  of  his 
taking  off. 

No  expenditure  of  care  is  too  great  to  avert  this  catastrophe.  The 
care  consists  in  (1)  always  using  a  disinfected  catheter — ^best,  a  clean 
new  instrument,  washed  in  water  nearly  boiling  ;  (2)  keeping  the  pa- 
tient warm  and  at  rest  after  using  the  catheter ;  (3)  never  emptying 
the  bladder  entirely  (if  it  contained  much  fluid  on  the  start)  until  the 
second  or  third  sitting  ;  (4)  washing  with  hot  borax  water  whenever 
the  bladder  is  emptied,  until  the  patient  is  habituated  to  the  use  of 
the  catheter.  If  cystitis  comes  on  it  must  be  treated  as  hereinafter 
directed. 

After  the  surgeon  has  elected  a  suitable  soft  instrument,  and  estab- 
lished a  tolerance  of  the  bladder  to  it,  and  brought  the  patient  through 
any  cystitis  or  surgical  fever  which  may  have  been  occasioned  by  the 
instrument,  the  next  step  is  to  instruct  the  patient  to  pass  the  catheter 
himself,  and  to  take  care  of  himself  locally,  probably  for  the  rest  of 
his  life.  He  is  directed  to  cover  himself  with  merino  in  summer  and 
flannel  m  winter.  His  feet  and  ankles  must  be  especially  well  pro- 
tected with  suitable  Avoolen  stockinets.     Tlie  feet  lie  farthest  from  the 


HYPERTROPHY— TREATMENT.  195 

heart,  the  source  of  heat.  From  their  pendent  position,  the  venous 
blood  has  great  natural  difficulties  in  getting  out  of  them.  They  are 
that  part  of  the  body  most  easily  chilled,  yet  habitually  they  are  the 
least  well  protected,  especially  by  old  men.  A  knowledge  of  these 
facts  indicates  the  natural  means  of  remedying  the  evil.  An  ordinary 
case  requires  no  change  in  diet.  Exercise  should  be  taken  at  will,  not 
on  horseback  at  first,  or  of  a  kind  attended  by  jolting,  as  this  tends 
mechanically  to  increase  the  congestion  about  the  base  and  neck  of 
the  bladder,  and  leads  to  an  aggravation  of  the  symptoms  (irritability) 
The  catheter  should  be  used  by  the  patient  more  or  less  often,  accord- 
ing to  the  quantity  of  residuum,  normal  intervals  of  urination  being 
observed  as  nearly  as  possible. 

In  ordinarily  mild  cases,  where  the  frequency  of  urination  comes  on 
mainly  at  night,  emptying  the  bladder  once  thoroughly  Just  before 
retiring  may  be  all  that  is  required.  After  this,  the  patient  will  sleep 
quietly  until  toward  morning,  when  the  residuum  will  have  re-col- 
lected, and  then  the  desire  to  pass  water  will  again  return.  Where 
the  residuum  is  large,  a  pint  or  more,  it  is  far  better  for  the  patient 
to  rely  entirely  upon  the  use  of  the  catheter,  introducing  it  three  or 
four  times  daily,  perhaps  five  or  six,  and  never  attempting  to  pass  a 
drop  of  urine  without  its  aid.  This  becomes  necessary  where  there  is 
a  valvular  condition  of  the  vesical  orifice,  or  such  other  deformity  as 
makes  it  impossible  for  the  patient  to  pass  any  water.  Here,  if  the 
catheter  enters  easily,  the  patient  is  perfectly  safe.  He  goes  around 
carrying  his  instrument  with  him.  He  becomes  proud  of  his  ability 
to  introduce  it,  and  does  it  better  than  any  one  can  do  it  for  him. 
Patients  may  go  on  in  this  way  for  many  years.  I  have  known 
several  cases  of  use  of  the  catheter  for  about  twenty  years.  Sir  H. 
Thompson*  knew  a  gentleman  of  ninety  who  had  passed  the  catheter 
for  twenty-two  years,  and  a  gentleman  of  Norwich  told  him  that 
he  had  passed  the  catheter  upon  himself  thirty-five  thousand  times, 
and  no  harm  had  come  of  it.  Thompson  made  some  observations 
with  Dr.  Messent  upon  old  men  in  Greenwich  Hospital,  and  found 
that,  while  the  average  age  of  death  there  was  seventy-three,  the 
average  age  of  death  of  those  who  used  a  catheter  was  seventy-two 
and  three  fourths,  a  very  excellent  showing  of  the  harmlessness  of 
using  a  catheter  habitually. 

Patients  who  have  considerable  atony  and  tolerant  bladders  have 
little  else  to  do  except  to  keep  their  bladders  clean  by  injections  of 
warm  water,  once  or  twice  daily,  to  prevent  the  formation  of  stone,  or 
the  lighting  up  of  inflammation  by  the  decomposing  urine,  and  to 
keep  themselves  supplied  with  catheters. 

The  question  now  naturally  arises.  Is  it  advisable  to  instruct  a 

*  Mentioned  at  a  meeting  of  the  Royal  Medical  and  Chirurgical  Society,  at  which  I 
was  present,  in  May,  18Y9. 


196  DISEASES   OF   THE   TROSTATE. 

patient  with  enlarged  prostate  in  the  use  of  the  catheter,  if  he  has  a 
very  small  amount  of  residuum  or  none  at  all  ?  Most  assuredly,  yes. 
If  there  is  no  residuum,  still,  with  the  slow  advance  of  the  disease,  a 
time  is  pretty  sure  to  come  when  there  will  be  a  certain  quantity,  or 
when,  from  the  effect  of  cold,  irritating  urine,  or  other  cause,  retention 
may  come  on.  It  is  a  rule  with  no  exceptions,  that  a  i)ationt  with 
hyper trophied  prostate  is  never  safe  unless  he  can  pass  a  catheter  for 
himself,  any  more  than  is  a  patient  with  hernia  who  does  not  wear  a 
truss.  Hence,  in  all  cases,  the  patient  should  be  taught  the  use  of  a 
soft  catheter,  be  provided  with  an  instrument,  and  instructed  in  the 
manipulation  of  washing  out  the  bladder,  both  for  purposes  of  clean- 
liness and  so  as  to  be  enabled  to  employ  medicated  injections.  If  the 
amount  of  residuum  is  small,  so  that  no  material  relief  is  afforded  by 
the  mere  draining  off  of  the  urine  which  the  patient  can  not  pass,  still 
the  force  of  the  above  reasoning  is  applicable,  and  the  utility  of  wash- 
ing out  the  bladder  is  equally  necessary,  since  the  liability  to  the 
formation  of  stone  exists  as  well  where  the  residuum  is  small  as  where 
it  is  large,  if  there  is  any  cystitis  and  retained  muco-pus. 

If  no  instrument  can  be  made  to  enter  the  bladder,  and  there  is 
retention,  the  aspirator  should  be  used  twice  daily  above  the  pubis  for 
a  time,  meanwhile  attempts  being  made  to  reach  the  bladder  with  the 
catheter.  If  all  efforts  finally  fail,  a  permanent  opening  must  be 
established  above  the  pubes,  or  a  radical  operation  done  through  the 
perinaeum. 

The  washing  out  of  an  hypertrophied  and  dilated  bladder,  where 
the  mucous  membrane  is  habitually  congested  and  secreting  an  over- 
supply  of  mucus,  is  a. point  of  treatment  of  cardinal  importance.  By 
this  means  the  last  drops  of  residual  urine,  with  the  pus  and  stringy 
mucus  which  they  contain,  are  diluted  and  drained  away,  and  no 
ferment  is  left  behind  to  decompose  the  healthy  fluid  as  it  comes 
down  the  ureters.  The  formation  of  stone  is  prevented,  and  the  con- 
gestion existing  around  the  neck  of  the  bladder  is  soothed  and  kept 
from  any  aggravation  which  would  increase  the  irritability — that  dis- 
tressing symptom  so  closely  linked  with  the  pathological  changes 
incident  to  enlarged  prostate.  The  best  method  of  washing  out  the 
bladder  is  as  follows  :  The  soft  catheter  through  which  the  residuum 
has  been  drawTi  off  is  used.  A  double-current  catheter  is  not  advisa- 
ble, for  with  such  an  instrument  no  distention  is  brought  to  bear 
upon  the  bladder-walls,  and  the  whole  mucous  surface  is  not  brought 
into  contact  with  the  cleansing  fluid.  Warm  water  should  be  used, 
since  it  is  soothing  as  well  as  cleansing,  and  does  not  excite  the  bladder 
to  speedy  contraction  upon  being  thrown  into  its  cavity.  A  tempera- 
ture of  about  blood-heat  should  be  aimed  at — a  little  below  100°  Fahr. 
The  best  instrument  for  a  surgeon  to  use  in  washing  the  bladder  is 
probably  the  bulb-syringe,  holding  about  six  ounces,  with  a  tapering 


IIYPERTKOPUY— TREATiMENT. 


107 


nozzle — so  that  it  may  fit  any  catheter  (Fig.  72).  The  pi.ston-.syringe 
or  the  Davidson  will  answer,  but  they  are  not  as  convenient.  The 
best  instrument  for  a  patient  to  use  in  washing  out  his  own  bladder 
is  the  fountain  syringe  (Fig.  73),  with  two-way  metallic  stop-cock  and 
hard-rubber  nozzle.     The  mechanism  is  obvious.     No  air  enters  the 


Fig.  72. 


Fig.  73. 


bladder,  and  repeated  washings  may  be  comfortably  effected  until  the 
bladder  is  clean,  without  any  more  trouble  than  turning  the  stop-cock 
back  and  forth. 

In  using  this  bag,  that  the  temperature  of  the  injected  fluid  may 
reach  the  bladder  at  about  100°,  it  must  be  started  in  the  bag  between 
110°  and  115°  Fahr.  In  injecting  a  bladder  with  any  instrument,  the 
fluid  should  be  gently  thrown  in  until  a  feeling  of  moderate  distention 
is  experienced,  when  it  should  be  allowed  immediately  to  escape,  a 
second  and  third  washing  being  resorted  to  until  the  wash  returns  clear 
— then  the  medicated  injection  should  be  thrown  in.  The  patient 
easily  learns  to  wash  his  own  bladder,  and  once  accustomed  to  it  he 
practices  it  voluntarily  whenever  the  urine  becomes  purulent  or  foul, 
because  he  learns  from  experience  the  advantage  of  keej^ing  his  blad- 
der clean.  The  frequency  of  the  washing  depends  upon  the  condi- 
tion of  the  urine. 

At  the  commencement  of  treatment  in  many  cases  where  the  irri- 
tation of  using  the  catheter  keeps  up  or  increases  the  mild  cystitis 


198  DISEASES   OF   THE   TROSTATE. 

already  existing,  and  causes  a  free  and  continued  secretion  of  pus,  it 
is  advisable  to  pass  from  simple  water  to  the  use  of  medicated  fluids 
in  injection.  These  may  be  first  employed  by  the  surgeon,  afterward 
intrusted  to  the  patient.  Nothing  better  can  be  suggested  for  the 
patient's  use  than  borax — pure  and  simple — from  a  heaping  dessert- 
spoonful to  a  tablespoonful  to  the  pint,  or  strong  lead-water  (Goulard's 
extract),  one  to  two  teaspoonfuls  to  the  pint.  The  surgeon  may  use, 
often  with  greater  advantage,  acetate  of  lead,  one  sixth  to  half  a  grain 
to  the  ounce  of  water ;  sulphate  of  zinc,  gr,  ss  to  ij  to  the  3  j;  one  to 
twenty  minims  of  dilute  nitric  acid  to  the  pint  of  water  ;  or,  best  of 
all,  in  some  cases,  nitrate  of  silver,  from  gr.  j  to  gr.  v  to  the  pint,  or 
stronger  in  cases  that  are  tested  and  studied.  Carbolic  acid  and  the 
bichloride  of  mercury  do  not  give  good  results  in  my  hands  ;  chlorate 
of  potash  and  boracic  acid,  silicate  of  soda,  permanganate  of  potash 
and  quinine,  I  have  abandoned.  I  have  sometimes  thought  that  I 
derived  a  little  benefit  from  injecting  a  solution  of  the  muriate  of 
hydrastin,  gr.  j-v  to  the  pint,  and  occasionally  from  the  use  of  mild 
solutions  of  hamamelis. 

In  certain  very  rare  instances  it  may  be  deemed  advisable  to  tie  in 
a  catheter  (p.  1^9).  None  but  a  soft  instrument  should  be  so  em- 
ployed, preferably  one  of  pure  caoutchouc,  as  they  will  remain  longest 
in  the  bladder  without  becoming  incrusted  with  urinary  salts.  Cases 
requiring  the  tying  in  of  a  catheter  are  those  in  which  introduction  is 
exceedingly  difficult,  and  the  patient  lives  at  a  distance  from  the 
surgeon,  or  where  the  neck  of  the  bladder  is  very  tolerant  of  an  instru- 
ment, and  it  is  desired  to  prevent  the  irritation  of  frequent  reintro- 
duction,  and  the  spasm  of  the  muscles  of  the  bladder  and  perina^um 
which  such  reintroduction  occasions.  Wherever  an  instrument  is  left 
tied  in,  whether  the  patient  is  walking  about  or  on  his  back,  the 
cavity  of  the  viscus  should  be  thoroughly  washed  out  with  warm  water 
several  times  daily,  and  the  instrument  removed  if  it  api)cars  to  be 
causing  irritation.  Sometimes  a  caoutchouc  instrument  may  be  worn 
for  months,  and  removed  still  clean,  if  the  bladder  has  been  syringed 
out  regularly. 

In  those  rare  cases  where  there  is  real  incontinence  (not  overflow), 
where  the  patient  is  constantly  leaking  slightly,  either  continuously  or 
by  little  jets,  caused  by  involuntary  spasmodic  muscular  contractions, 
or,  finally,  in  any  case  where  the  patient's  calls  recur  at  short  intervals, 
and  the  nature  of  his  occupation  is  such  that  he  is  not  sure  of  always 
being  able  to  reach  quickly  a  place  where  he  can  relieve  himself,  he 
should  constantly  wear  a  urinal. 

Of  the  many  varieties  of  this  instrument  found  in  the  shops,  only 
one  accomplishes  the  two  necessary  objects  of  being  safe  as  well  as 
comfortable.  Tlie  urinal  referred  to  (Fig.  74)  was  devised  by  a  pri- 
vate gentleman  of  this  city,  suffering  from  true  incontinence.     He 


HYPEllTROPUY— TREATMENT. 


199 


was  accustomed  to  dine  out  frequently,  and  related  with  enthusiasm 
the  satisfaction  he  experienced,  when  conversing  in  the  evening  with 
a  lady  guest,  to  feel  the  urine  trickle  down  his  thigh,  with  the  con- 
viction that  it  was  going  to  the  right  place,  and 
could  not  disgrace  him. 

The  construction  of  tliis  urinal  is  most  sim- 
ple. It  is  made  of  soft  rubber,  in  the  form  of 
a  large  pouch,  capable  of  receiving  the  whole 
scrotum  as  well  as  the  penis,  and  large  enough  to 
allow  a  free  circulation  of  air  around  the  parts, 
thus  preventing  sweating  or  excoriation.  From 
this  pouch  two  broad  bands  of  rubber  extend  up 
flatwise,  one  over  the  belly,  the  other  over  the 
nates  to  the  waist,  where  they  are  attached  by 
buttons  to  the  suspenders.  Below,  the  pouch 
terminates  in  a  long,  flat  bag,  attached  by  tapes 
to  the  thigh  and  leg,  and  reaching  nearly  to 
the  ankle,  so  that  no  urine  collecting  in  it  can 
possibly  spill  out  during  any  ordinary  motion. 
A  metallic  cap  at  the  bottom  unscrews  to  drain 
oS  the  urine  and  clean  the  instrument,  which 
should  be  washed  out  daily  with  a  mild  solution 
of  permanganate  of  potash. 

Treatment  of  Complications. —  During  the 
use  of  the  catheter,  one  or  both  testicles  may 
swell.  This  is  not  a  matter  of  serious  impor- 
tance, and  may  be  overcome  by  the  treatment 
for  epididymitis.  If  the  pain  is  severe,  or  if  position  alone  relieves 
the  pain,  as  it  usually  will  do,  there  is  no  necessity  for  anything 
further  ;  introduction  of  the  catheter  may  be  continued,  and  the  swell- 
ing will  subside. 

What  is  liable,  however,  to  give  most  trouble  early  in  the  treatment 
by  repeated  catheterization  is  the  congested  condition  of  the  neck  of 
the  bladder.  In  most  cases,  especially  where  retention  has  come  on, 
this  congestion  is  considerable,  and  is  readily  aggravated,  the  slight 
violence  done  in  catheterism  lighting  up  a  little  cystitis  about  the 
neck,  or  increasing  what  already  existed.  Cystitis  announces  itself 
by  increased  uneasiness  when  the  bladder  contains  only  a  slight  amount 
of  urine,  tendency  to  spasmodic  contraction  of  the  bladder-walls,  un- 
less they  are  atonied,  increased  amount  of  pus  in  the  urine,  and 
almost  always  by  the  presence  of  blood  in  greater  or  less  quantities. 
This  amount  of  cystitis  is  most  apt  to  come  on  during  treatment  of  a 
bladder  already  somewhat  irritable,  where  there  is  not  much  atony  or 
after-retention.  Old  cases,  where  the  organ  has  been  overdisteuded 
by  a  very  large  residuum  for  years,  are  not  liable  to  suffer  much  from 


Fig.  74. 


200  DISEASES  OF  THE   PROSTATE. 

the  introduction  of  the  catheter,  provided  the  bhidder  is  judiciously 
(not  too  suddenly)  emptied.  When  cystitis  of  the  neck  comes  on, 
calls  to  urinate  will  become  more  and  more  frequent,  the  last  part  of 
the  urine  drawn  through  the  catheter  will  be  tinged  with  blood,  per- 
haps blood  will  continue  to  flow  into  the  bladder  after  the  withdrawal 
of  the  catheter,  so  that  the  next  urine  passed  or  drawn  will  resemble 
pure  blood,  or  may  be  nearly  as  black  as  ink,  if  it  has  been  retained 
for  some  time ;  or,  again,  if  blood  flows  freely  and  quickly  into  an 
empty  bladder,  it  may  fill  it  to  a  certain  extent,  clotting  into  a  solid 
mass  in  its  cavity. 

None  of  these  conditions  need  cause  alarm.  If  the  flow  of  blood  is 
excessive,  and  the  bladder  has  power  to  empty  itself,  it  is  expedient  to 
intermit  the  use  of  the  catheter  for  a  time,  otherwise  it  must  be  con- 
tinued, employing  the  utmost  gentleness  of  maniiiulation.  Unless 
cystitis  of  the  neck  becomes  a  prominent  complication,  the  bleeding, 
on  the  use  of  the  catheter,  will  cease  in  a  few  days,  and  then  the 
patient  may  be  allowed  to  get  out  of  bed  and  gradually  to  resume  his 
ordinary  habits  of  life,  relying  on  warm-vv^ater  injections  to  keep  the 
bladder  clean  and  the  residuum  from  decomposing.  When  the  flow 
of  blood  and  irritation  around  the  vesical  neck  are  considerable,  opium, 
in  suppository,  is  advisable  for  a  few  days.  If  the  bladder  becomes 
filled  bva  clot,  no  attempts  to  break  it  ujo  or  dislodge  it  are  admissible. 
It  will  gradually  soften,  dissolve,  and  come  away  in  the  urine,  which 
should  be  kept  abundant  and  alkaline.  Sometimes  pain  is  so  great 
that  the  clot  has  to  be  removed,  which  may  be  properly  attempted 
by  injecting  hot  water  containing  about  one  quarter  or  one  sixth  of  a 
fifteen-volume  solution  of  peroxide  of  hydrogen. 

In  the  great  majority  of  cases  the  above  treatment  will  cover  the 
ground,  and  afford  all  the  relief  the  patient  can  hope  to  find,  general 
hygiene  being  regulated,  exposure  to  cold  particularly  avoided,  the 
urine  kept  from  becoming  too  acid,  and  the  patient  being  made  his 
own  physician.  Some  patients  can  not  get  along  without  the  occa- 
sional insertion  of  an  anodyne  suppository,  but  the  use  of  such  means 
of  relief  should  never  be  placed  in  his  hands  unless  he  is  made  fully 
aware  of  the  danger  of  abusing  his  power.  In  some  cases,  after  reten- 
tion, the  bladder  will  gradually  reacquire  its  contractile  power,  and  the 
amount  of  residuum  will  be  lessened,  but  this  is  rare.  The  atonied, 
overstretched  bladder  of  an  old  man  does  not  recover  its  tone  like 
that  of  a  youth,  and  indeed  it  is  better  that  it  should  not.  The 
patient  should  be  encouraged  to  rely  entirely  upon  his  instrument,  and 
not  to  strain  to  use  his  bladder. 

Some  cystitis  almost  invariably  exists,  in  a  greater  or  less  degree, 
before  the  patient  applies  for  treatment,  and  it  is,  in  fact,  often  for 
relief  from  the  symptoms  caused  by  it  that  he  so  applies.  The  cystitis 
gives  rise  to  his  frequent  calls  to  urinate,  and  supplies  the  in\s  and 


II  YPERTROniY— TREATMENT.  201 

stringy  mucus  with  wliich  his  urine  abounds.  A  mild  degree  of  cystitis 
will  subside  spontaneously,  as  a  rule,  under  the  improved  condition  of 
the  bladder  produced  by  draining  off  its  residuum  and  washing  out  its 
cavity. 

Internal  Remedies  in  Cases  of  Hypertrophy. — When  the  cystitis 
seems  to  be  getting  unmanageable,  when  the  calls  to  urinate  arc  fre- 
quent and  painful,  or  in  any  case  when  the  amount  of  pain  is  con- 
siderable, it  is  better  to  use  an  anodyne  suppository,  which  may  best 
consist  of  codeine  (gr.  j-ij),  watery  extract  of  opium  (gr.  ss-ij),  or 
morphine  (gr.  -|-j).  Camphor  is  occasionally  added  to  these  supposi- 
tories for  the  purpose  of  obtaining  more  effect  with  the  employment 
of  less  opiate,  or,  more  often,  extract  of  belladonna,  with  the  alleged 
object  of  allaying  spasm.  The  efScacy  of  both  these  latter  agents  is 
overrated.  The  object  is  to  allay  pain,  and  pain  only  justifies  us  in 
using  opiates.  The  frequency  of  calls  to  urinate  may  be  great,  but,  if 
there  is  not  pain  as  well,  there  is  no  indication  for  anodynes.  The 
amount  used  should  be  barely  sufficient  to  control  the  pain,  and  should 
be  subdivided  into  many  small  doses  (three  to  four  in  the  twenty-four 
hours),  rather  than  given  all  at  once,  or  even  night  and  morning. 
Laudanum  or  other  fluid  may  be  used  instead  of  solid  suppositories. 
The  reason  why  anodynes  are  of  no  service  by  injection  into  the  blad- 
der is  that  only  a  small  amount  is  absorbed,  unless  the  solution  in- 
jected be  concentrated,  while  the  bladder  epithelium  is  entire  ;  but, 
should  an  abrasion  or  ulcer  exist,  the  amount  absorbed  may  be  very 
considerable,  producing  more  effect  than  was  desired.  Atropine  or 
belladonna,  in  sufficient  doses,  will  lengthen  the  intervals  of  urination, 
and  modify  pain  ;  but  the  agent  is  in  many  cases  uncertain  in  its  action 
and  difficult  to  manage — in  some  cases  it  acts  well.  One  twenty-fifth 
of  a  grain  of  sulphate  of  atropine  in  water  is  a  proper  dose  to  com- 
mence with,  increasing  gradually  until  an  effect  is  obtained,  and  watch- 
ing the  patient  for  symptoms  of  poisoning. 

When  cystitis,  accompanying  enlarged  prostate,  becomes  considera- 
ble enough  to  require  the  use  of  anodynes,  the  recumbent  position 
should  be  insisted  upon.  The  patient  should  lie  upon  his  back  with 
a  hair  pillow  under  the  hips,  so  that  they  may  be  raised  higher  than 
his  shoulders,  in  this  way  relieving  the  bladder  from  some  of  the  in- 
testinal pressure,  and  favoring  a  drainage  of  venous  blood  from  the 
pelvis.  The  head  may  be  raised,  but  the  shoulders  must  be  low. 
The  skin  of  the  hypogastrium  should  be  kept  slightly  reddened  by 
the  application  of  a  hot,  light  poultice,  containing  a  sprinkling  of 
mustard,  or  more  neatly  by  the  use  of  moistened  mustard-paper,  and 
a  flat  rubber  bag,  containing  hot  water,  which  may  be  laid  upon  it. 
Heat,  applied  also  to  the  perinseum,  is  agreeable  to  the  patient. 
These  bags  afford  great  comfort.  The  rectum  should  be  kept  empty 
by  the  daily  use  of  a  hot  enema.     Water,  as  warm  as  can  be  borne 


202  DISEASES  OF  THE  PROSTATE. 

ill  the  rectum,  often  exercises  a  decidedly  soothing  effect  upon  the 
inflamed  bladder. 

The  only  internal  remedies  which  seem  to  be  of  nnich  service  are 
the  different  alkaline  diuretics  and  diluents.  Of  the  former,  citrate  of 
potash,  in  gr.  xx-xxx  doses,  three  or  four  times  daily,  according  to 
the  concentration  and  acidity  of  the  urine,  is  pcrlnqis  the  best.  It 
may  be  alternated  with  bicarbonate  of  soda,  acetate  of  })olash,  or  liquor 
potassa\  The  alkali  may  be  given  in  carbonated  water,  flaxseed-tea, 
or  in  whatever  diluent  is  selected.  The  variety  of  this  latter  class  of 
remedies  is  innumerable.  All  of  them  are  doubtless  of  value,  but  none 
possess  specific  qualities.  They  should  be  taken  largely.  The  one 
]ierhaps  most  generally  useful  as  well  as  agreeable  is  ordinary  flaxseed- 
tea  flavored  with  lemon-peel  (lemon-Juice  is  to  be  avoided)  and  sugar, 
and  taken  cold  or  warm,  to  the  extent  of  from  one  to  three  pints  in 
the  twenty-four  hours.  Buchu,  so  popular  in  this  country,  may  be 
combined  with  it  in  infusion,  from  three  to  six  ounces  daily.  Thomp- 
son speaks  well  of  a  decoction  of  the  underground  stem  of  the  Triti- 
cum  repcns,  made  by  boiling  two  ounces  of  the  root  for  a  quarter  of 
an  hour  in  a  pint  of  water.  This  is  strained,  and  the  w^hole  taken  in 
four  doses  during  twenty-four  hours.  If  the  patient  tire  of  one  decoc- 
tion or  infusion,  it  may  be  changed  for  another — pareira  brava,  nva 
ursi,  corn-silk. 

The  old  combination  of  hyoscyamus  and  liquor  potassas,  chemically 
incompatible,  is  clinically  often  of  decided  service.  The  old  form  of 
prescription  made  with  the  tincture  is  not  so  useful,  on  account,  possi- 
bly, of  the  alcohol  it  contains,  as  the  same  made  from  the  extract  of 
henbane.  The  following  formula  has  proved  quite  eflScient  in  mod- 
erating frequent  and  painful  micturition  : 

5     Liq.  potass£E,  3  ij^  §  ss. 

Extr.  hyoscyami,  f  3  j- 

Syr.  aurant.  cort.,  )  or,  Mist,  acacias, 

Aquae  cinnam.,  ila  3  iij.  )        Aquae,  au  3  iij. 

M.     S.  A  tablespooaful  in  some  diluent  every  eight  hours. 

As  has  already  been  several  times  stated,  the  urine  coming  from  the 
kidneys,  in  these  cases  of  bladder  disease  depending  upon  obstruction 
to  the  free  outflow  of  urine,  is  nearly  always  acid,  over-acid  indeed, 
'oecoming  alkalinized  in  the  bladder,  and  the  object  of  giving  alkalies 
by  the  mouth  is  to  render  the  urine  less  irritating  to  the  sensitive  lin- 
ing membrane  of  the  bladder.  Ilence  the  impossibility,  and  indeed 
the  inappropriateness,  of  endeavoring  to  render  the  urine  acid  by  ad- 
ministering acids. 

By  the  employment  of  the  above  means,  aided  by  a  large  share  of 
patience,  the  washings  of  the  bladder  being  regularly  and  gently  at- 
tended to,  cases  of  vesical  catarrh  depending  on  prostatic  obstruction 
will  gradually  get  well  up  to  a  certain  point,  not  incompatible  with 


nYPERTROniY— TREATMExXT.  203 

the  exercise  of  all  his  functions  by  the  patient,  and,  provided  only  he 
attend  scrupulously  to  keeping  his  bladder  clean  by  warm-water  in- 
jections, leaving  him  capable  of  enjoying  a  life  as  long,  as  comfortable, 
and  as  useful  as  if  his  bladder  were  sound.  This  statement,  of  course, 
does  not  apply  if  either  of  the  three  complications,  so  common  with 
this  form  of  disease,  exists — namely,  stone,  mild  pyelitis,  or  fatty  atro- 
phy of  the  kidneys.     Where  stone  is  present,  it  must  be  removed. 

The  radical  treatment  of  enlarged  prostate  by  medicine  is  in  my 
opinion  a  delusion.  The  cases  recorded  prove  nothing.  Many  a  man 
has  enlarged  prostate  and  retention,  and  uses  a  catheter  for  a  longer  or 
shorter  period,  and  then  under  milk  diet  or  improved  health  he  recov- 
ers his  expulsive  power  and  abandons  his  catheter.  I  have  several 
instances  of  this  among  my  patients,  none  of  whom  took  ergot,  while 
I  have  given  ergot  in  large  and  small  doses  to  scores  of  people  for 
months  at  a  time,  and  I  have  yet  to  see  the  first  case  that  derived  any 
advantage  from  the  drug  that  I  could  appreciate.  The  same  is  my 
opinion  of  the  interstitial  injection  of  ergot  or  of  iodine  into  the  pros- 
tate (Heine's  method).  By  this  method  Dittel*  once  produced  acute 
prostatitis  with  suppuration. 

The  surgical  means  for  reducing  the  size  of  the  prostate  are  radical 
and  often  effective.  Harrison's  f  suggestion  of  puncturing  through 
the  substance  of  the  prostate  and  leaving  in  a  silver  tube,  to  produce 
atrophy,  I  have  not  tried.  The  method  of  Mercier — of  crushing  off  a 
portion  of  a  third  lobe,  or  of  a  prostatic  bar — is  not  accurate  enough, 
and  is  too  rough  to  be  good  surgery.  It  sometimes  yields  good  results, 
but  the  same  can  be  accomplished  better,  more  surgically,  and  with 
no  greater  risk  to  the  patient. 

The  method  of  Bottini,J  of  Pavia — namely,  incision  of  third  lobe 
by  a  galvanic  cautery  prostatotome  passed  through  the  urethra — is 
open  to  the  same  objections,  besides  requiring  special  apparatus  and 
some  skill  as  an  electrical  expert.  Good  results,  however,  have  been 
reported  from  its  use. 

But  the  best  radical  methods  are  undoubtedly  either  (1)  suprapubic 
cystotomy  for  ablation  of  the  third  lobe,  which  is  of  easy  accomplish- 
ment and  yields  good  results,  although  it  is  an  operation  too  serious 
to  be  lightly  undertaken  for  a  malady  which  itself  does  not  kill,  and 
may  be  so  readily  alleviated  as  to  its  symptoms  ;  or  (3)  perineal  section 
with  ablation  of  any  interstitial  tumor  which  may  project  into  the 
incision,*  or  most  often  cutting  or  tearing  away  of  third  lobe  or  jDro- 

*  "Centralblatt  f.  Chirurgie,"  November  27,  18*76. 

•)•  "Lithotomy,  Lithotrity,"  etc.,  London,  1883,  p.  65. 

X  Described  at  length  with  many  other  methods  in  the  excellent  article  "  Prostate," 
in  the  "  Nouveau  Diet,  de  Med.  et  de  Chir.  Prat." 

*  Sir  William  Laurence  had  such  a  case.  Reported  by  FeFguson,  "  Med.  Times  and 
Gazette,"  April  18  and  May  23,  1857.  Harrison  had  another,  and  others  have  been 
reported — Keith,  Thompson. 


0(jj.  DISEASES   OF   THE   PROSTATE. 

jecting  portions  of  prostate  through  the  incision  ;  or,  linally,  slitting 
through  third  lobe  or  prostatic  bar,  tying  in  a  large  tube,  and  allow- 
ing a  new  floor  to  the  prostate  to  form  by  cicatrization  about  the  tube. 
Both  these  latter  operations  I  have  done  a  number  of  times,  always 
with  relief  to  the  patient,  although  what  may  be  called  a  positive  cure 
can  not  generally  be  effected.  In  one  instance,  however,  I  restored 
to  a  patient  who  had  only  urinated  through  a  catheter  for  four  years 
the  power  of  voluntary  urination  by  taking  away  his  third  lobe  through 
a  perineal  incision,  and  a  number  of  patients  with  cystitis  of  high  grade 
have  been  greatly  benefited  at  my  hands  by  perineal  drainage  combined 
with  cutting  into  the  floor  or  taking  away  an  outstanding  portion  of 
prostate.  These  radical  measures  I  can  therefore  heartily  indorse  in 
severe  cases  when  palliative  means  fail  to  comfort  the  patient  or  to 
protect  his  general  health. 

Mode  of  Death  in  Cases  or  HYPEETROPnY. — The  not  very  infre- 
quent complication  of  a  low  grade  of  inflammation  of  the  ureters  and 
pelves  of  the  kidneys  is  always  a  serious  matter.  This  becomes  easily 
aggravated  by  cold  or  imprudence  in  diet,  developing  at  once  symp- 
toms of  mild  urtemia,  with  hot,  dry  skin,  loss  of  appetite,  slee})lessness, 
great  restlessness,  dry,  red,  or  pasty  tongue,  parched  mouth,  tendency 
to  depression,  headache,  tendency  to  wandering  of  the  intellect,  con- 
stipation— all  this  attended,  as  a  rule,  by  polyuria,  a  little  albumen, 
and  a  few  pale  casts  in  the  urine.  A  fatal  termination  of  these  symp- 
toms is  a  not  uncommon  mode  of  death  in  cases  of  prostatic  disease. 
The  complication  is  best  treated  by  confining  the  patient  to  bed,  in  a 
room  where  the  air  can  be  frequently  renewed,  and  the  temperature 
kept  high,  at  80°  Fahr.  or  thereabouts  ;  exciting  the  action  of  the  skin 
and  bowels  ;  giving  diluents  in  abundance,  and  a  mild  (milk)  diet. 
The  combination  of  potash  and  hyoscyamus  acts  well  upon  these  cases, 
and  some  mild  stimulant  is  not  only  admissible,  but  necessary  to  keep 
up  the  general  strength  until  kidney  congestion  has  subsided.  These 
evils  are  more  easily  avoided  than  cured. 

A  more  uncommon  but  a  possible  cause  of  death  is  peri-  and  epi- 
cystitis  with  their  complications.  A  remarkable  case  of  perforation 
of  the  bladder  after  prolonged  retention,  due  to  prostatic  disease  with 
extensive  suppuration  burrowing  upward  into  the  pleural  cavity,  is 
recorded  by  Duplay.* 

*  "Arcbiv.  Gen.,"  March,  1811,  p.  604. 


CONGESTION   OF   THE   PKOSTATK.  £05 


CHAPTER  XL 

DISEASES   OF  THE  PROSTATE. 

Congestion.  —  Parenchj'matous  Prostatitis.  —  Terminations:  in  Resolution,  f;liroi)ic  Prostatitis, 
Abscess.— Treatment.— Gonorriiocal  Prostatitis.— Prostatic  and  Peri-prostatic  Abscess.— Treat- 
ment of  all  Forms  of  Abscess.— Follicular  Prostatitis.— Its  Liability  to  be  mistaken  for  Stone 
in  the  Bladder. — Treatment.— Tubercular  Prostatitis.— Cancer  of  the  Prostate.— Prostatic  Con- 
cretions.— Prostatic  Calculi. — Neuralgia  of  the  Prostatic  Urethra.— Syphilis  of  the  Prostate. 

Coi«rGESTiON"  of  the  prostate  occurs  physiologically  during  venereal 
excitement.  If  such  excitement  be  unduly  prolonged  without  being 
gratified,  even  sometimes  without  erection,  if  the  imagination  be  given 
up  to  erotic  fancies,  the  mucous  follicles  of  the  organ  secrete  more  or 
less  of  a  peculiar,  viscid,  bluish  mucus,  without  odor,  which,  mixed 
with  urethral  mucus,  finds  its  way  out  at  the  meatus.  This  phe- 
nomenon is  perfectly  natural.  Physiologically  it  is  analogous  to  the 
watering  of  the  mouth  of  a  hungry  individual  at  the  sight,  smell,  or 
even  thought  of  food.  Many  individuals,  however,  whose  sexual  re- 
quirements are  not  met,  live  in  such  a  state  of  mental  inquietude, 
particularly  in  regard  to  the  genito-urinary  organs,  that  this  drop  of 
mucus  appearing  during  erection  excites  in  their  minds  the  most  lively 
alarm,  and  they  hasten  to  their  surgeon  to  demand  his  aid  for  sper- 
matorrhoea, stating  that  they  never  have  an  erection  without  the  in- 
voluntary emission  of  seminal  fluid. 

Of  this  idea  it  is  often  hard  to  dispossess  the  patient's  mind,  but 
an  honest  explanation  of  the  whole  subject  will  rarely  fail  to  convince 
him  ;  while  the  observance  of  purity  of  thought  and  the  avoidance  of 
occasions  of  sexual  excitement,  or,  better  still,  marriage,  to  place  him 
in  natural  sexual  relations,  will  prove,  infallibly,  effective  of  cure. 

If  this  physiological  hyperemia  be  kept  up  for  a  long  time  (several 
hours),  the  prostate  is  liable  to  remain  congested,  throbbing  slightly, 
feeling  full  and  hot,  giving  rise,  perhaps,  to  frequent  calls  to  urinate, 
and  attended  by  a  very  slight  gleety  discharge.  If  the  patient  urinate 
frequently,  straining  to  empty  the  bladder  of  its  last  drops,  the  pros- 
tatic congestion  is  maintained  and  aggravated.  All  these  uncomfort- 
able feelings,  due  to  prostatic  congestion,  are  relieved  by  rest ;  more 
quickly  by  a  cold  sitz-bath,  or  by  a  very  hot  sitz-bath  of  short  duration. 
The  desire  to  urinate  produced  by  the  contact  of  water  should  not  be 
yielded  to. 

Slight  congestion  of  the  prostate  frequently  comiDlicates  gonorrhoea, 
stricture,  etc.  It  is  usually  ephemeral  in  character,  announcing  itself 
only  by  a  little  increased  frequency  of  urination,  or  it  may  continue 


206  DISEASES  OF  THE  PROSTATE. 

on  to  actual  inflammation.  Congestion  may  be  excited  in  the  pros- 
tate by  sexual  excess,  masturbation,  etc.,  and  this,  boinfj  kept  up  and 
often  repeated,  may  lead  to  chronic  follicular  jn'ostatitis,  without 
passing  through  any  acute  stage. 


PROSTATITIS. 

Inflammation  of  the  prostate  is  of  two  kinds  : 

1.   Parenchymatous.     2.  Follicular. 

Paeenchymatol's  Prostatitis. — Spontaneous  (primary)  inflam- 
mation of  the  prostate  is  rare  ;  inflammation,  traumatic,  or  extending 
to  the  prostate  from  contiguous  parts,  is  not  uncommon. 

Causes. — Among  the  causes  of  prostatitis  may  be  enumerated 
gonorrhoea,  stricture,  extreme  and  prolonged  sexual  excitement,  con- 
centrated acid  urine,  cold,  violence  from  instruments,  stone  fragments, 
etc.:  chemical  irritants,  strong  injections,  cantharides  internally,  etc. 
Gonorrho^al  inflammation,  after  the  first  week,  may  run  rapidly  down 
the  urethra  and  involve  the  prostate,  particularly  if  the  patient  in- 
dulge in  liquor,  sexual  intercourse,  or  take  violent  exercise,  or  use 
strong  injections,  throwing  them  deep  in  the  canal.  Sometimes,  dur- 
ing gonorrhea,  without  apiircciable  exciting  cause,  the  prostate  in- 
flames. The  inflammation  behind  a  stricture  may  run  back  and 
involve  the  prostate  in  the  same  way.  Sexual  hyperaemia,  too  much 
prolonged  or  too  often  repeated,  may  lead  to  it. 

Course. — Prostatitis  commences  as  congestion.  Passing  on  to 
true  inflammation,  it  terminates  by  resolution,  exudation  of  pus  on  the 
free  surface,  perhaps  by  croupous  exudation  ;  by  abscess,  or  peri- 
prostatic formation  of  pus  ;  or,  finally,  it  may  linger  indefinitely  as  a 
chronic  (follicular)  inflammation,  mild  in  degree,  occasionally  becom- 
ing aggravated. 

Symptoms. — The  organ  swells  rapidl}^  putting  the  capsule  on  the 
stretch,  and  often  reaching  the  size  of  a  small  orange.  It  may  feel 
square  (Vidal),  or  be  unevenly  enlarged.  The  exjiloring  finger  in  the 
rectum  strikes  at  once  against  this  mass,  which  juts  into  the  cavity  of 
the  gut,  is  very  tense  and  hot,  and  can  be  felt  distinctly  to  pulsate. 
It  is  exceedingly  sensitive  to  pressure — unlike  prostatic  hypertrophy, 
which  is  not  sensitive  unless  inflammation  be  present.  In  prostatitis 
the  lightest  touch,  even  the  presence  alone  of  the  finger  in  the  rectum, 
at  once  excites  a  desive  to  urinate.  Pressure  over  the  pubes  brings  on 
the  same  desire.  The  patient  is  conscious  of  something  protruding 
into  the  rectum,  and  may  experience  an  unnatural  desire  to  go  to  stool. 
If  he  endeavor  to  do  this,  he  strains  ineffectively,  causing  himself  pain, 
but  getting  no  relief,  even  if  he  succeed  in  forcing  out  a  little  fecal 
substance,  after  suffering  great  distress  in  the  effort.  The  peringeum 
feels  hot,  and  is  sensitive  to  pressure.      The  subjective  sensations. 


ACUTE  PROSTATITIS.  207 

locally,  arc  heat,  weight,  throbbing.  There  is  a  sort  of  drugging  feel- 
ing oyer  the  lower  part  of  the  abdomen,  as  well  as  in  the  penis  and 
scrotum.  There  may  be  pain  in  the  back  and  limbs.  If  gonorrhoea 
be  the  cause,  or  stricture  with  profuse  gleet,  the  urethral  discharge 
ceases  at  once,  or  becomes  very  scanty  and  thin.  It  returns,  however, 
as  the  prostatic  inilammation  subsides.  The  stream  of  urine  is  small 
and  is  passed  with  eifort.  The  prostate  may  swell  to  such  an  extent 
as  to  obliterate  the  prostatic  urethra  entirely  for  a  time,  causing  reten- 
tion. Thompson  believes  tliis  to  be  the  cause  of  all  retentions  which 
occur  during  acute  gonorrhoea — in  fact,  of  all  retentions  supposed  to 
be  produced  by  so-called  inflammatory  stricture  ;  but  this  is  certainly 
wrong,  urethral  spasm  is  most  often  at  fault. 

With  this  swelling  of  the  prostate  is  almost  invariably  associated 
congestion  of  the  vesical  neck,  and  a  constantly-recurring,  never-satis- 
fied desire  to  urinate.  If  retention  comes  on,  as  it  rarely  does,  this 
feeling  exists  as  a  matter  of  course ;  but,  even  when  the  bladder  is 
entirely  empty,  it  feels  partly  filled,  there  is  no  sensation  of  relief  after 
voiding  the  urine,  and,  when  a  few  drachms  have  re-collected,  the 
urgency  of  the  sensation  forces  the  patient  to  another  effort,  equally 
unsatisfactory.  The  urine  causes  j)ain  on  its  passage,  but  the  pain  is 
most  severe  as  the  last  drops  are  being  expelled,  when  the  circular 
fibers  at  the  bladder's  neck  squeeze  the  tender  prostate.  It  is  now  that 
blood  is  often  discharged  from  the  overloaded  vessels,  coloring  the  last 
drops  of  the  stream.  A  pain  like  that  occurring  with  stone  is  experi- 
enced, both  in  the  peringeum  running  down  the  urethra  and,  often 
with  greatest  intensity,  on  the  under  surface  of  the  penis  in  the  ure- 
thra, at  about  three  quarters  of  an  inch  from  the  meatus.  Coinciding 
with  all  these  features,  which  map  out  the  disease  so  plainly  that  it 
is  impossible  to  mistake  it,  there  is  general  febrile  disturbance,  with 
usually  the  utmost  concern,  apprehension,  disquietude,  and  depression 
with  excitement  of  mind,  such  as  is  rarely  caused  by  inflammations  of 
much  greater  magnitude,  and  attended  by  far  more  severe  pain  else- 
where. The  patient  is  irritable,  despondent,  and  suspicious ;  often, 
in  fact,  wild  to  an  extent  amounting  to  mild  acute  mania.  He  can 
not  sleep,  he  will  not  eat,  and  it  is  with  difficulty  that  he  can  be  kept 
quiet.  Fortunately,  his  feverish  condition  induces  him  to  drink  abun- 
dantly of  mild,  bland  fluids. 

The  inflammation  may  subside  before  the  malady  has  reached  this 
point.  Resolution  may  come  on  at  any  time,  even  after  the  above 
extreme  has  been  reached  ;  the  throbbing  pain  and  heat  disappear,  and 
usually  a  little  discharge  appears  from  the  prostatic  sinus.  This  dis- 
charge may  continue  for  a  considerable  period  (follicular  prostatitis), 
or  may  rapidly  cease  while  the  calls  to  urinate  grow  less  frequent,  and 
the  sensation  after  the  act  approaches  the  full  relief  felt  normally.  If 
the  inflammation  has  extended  into  the  seminal  vesicles,  there  may  be 


208  DISEASES  OF  THE   PROSTATE. 

spermatozoa  in  the  discharge.  A  false  membrane  may  form  in  the 
prostatic  sinus,  but  this  is  exceedingly  rare.  Finally,  the  inllamma- 
tiou  may  extend  down  the  vata  deferentia,  linger  in  a  chronic  form  in 
the  seminal  vesicles,  or  pass  on  to  light  up  epididymitis. 

If  the  inllamination,  instead  of  undergoing  resolution  or  passing  to 
a  chronic  state,  continue,  abscess  is  the  result.  Resolution  usually 
takes  place  between  the  fourth  and  twelfth  day,  and  recovery  is  com- 
])lete  in  from  one  to  three  weeks.  Possibly,  instead  of  recovering  or 
continuing  as  a  distinct  folliculitis,  chronic  interstitial  inllammation 
may  remain  behind,  leading  to  induration  and  general  tumefaction  of 
the  gland,  which  nuiy  persist  for  months  or  years,  and  may  even  be 
described  and  treated  as  hypertrophy.  This  kind  of  (false)  hyper- 
trophy giA'es  good  results  with  pressure,  electricity,  etc.,  namely,  ab- 
sorption of  the  iutlammatory  product,  and  thus  is  excited  the  vain 
hope  of  a  similar  result  where  true  hypertrophy  exists. 

Treatment. — No  point  of  treatment  is  so  essential  as  rest  in  any 
congested  or  inflamed  condition  of  the  prostate.  Eepose,  as  nearly 
absolute  as  possible,  may  bring  about  resolution  where  otherwise  sup- 
puration would  have  ensued.  The  tripod  of  safety  for  a  patient  with 
prostatitis  is  rest  in  bed,  some  alkaline  diluent  for  the  urine,  and 
enough  anodyne  to  control  severe  pain  and  excessive  action  of  the 
bladder.  The  rest  should  be  in  bed,  the  patient  lying  upon  his  back 
with  the  hips  raised.  The  bladder  should  be  restrained  from  contract- 
ing as  much  as  possible  by  the  exercise  of  the  will,  while  forcible  efforts 
at  emptying  the  last  drops  of  urine — to  which  the  patient's  feelings 
impel  him — should  be  interdicted.  For  the  same  reason  cathartics 
should  not  be  administered.  Copious  enemata  of  hot  water  carefully 
given  are  preferable.  The  jutting  out  of  the  tense  prostate  into  the 
rectum  gives  the  patient  a  constant  idea  that  the  lower  bowel  is  occu- 
pied by  fieces,  and  of  this  notion  it  is  ditHcult  to  divest  him.  He  must 
not  be  allowed,  however,  to  indulge  in  straining  at  stool,  as  this  action 
asrsrravates  his  condition.  As  for  medicine,  none  is  needed  in  a  mild 
case  except  jjlenty  of  bland  fluid — flaxseed-tea,  infusion  of  triticum 
repens,  etc.,  with  some  citrate  of  potash  or  Vichy  water.  By  these 
means  the  irritating  properties  of  the  urine  are  counteracted.  The 
combination  of  liquor  potassaB  with  extract  of  hyoscyamus  (page  202) 
seems  to  suit  certain  cases.  AVatery  extract  of  oi)ium,  codeine,  or 
morphine,  may  be  used  in  suppository,  gently  introduced,  in  sufficient 
(pumtities  to  modify  the  urgent  desire  to  urinate.  These  means,  com- 
bined with  a  light  diet,  will  bring  on  resolution  in  a  few  days  in  many 
cases. 

GONORKHCEAL  PROSTATITIS. — If  the  prostatic  affection  comes  on 
during  a  gonorrhoea,  all  active  treatment  of  the  latter  must  be  aban- 
doned. It  is  particularly  essential  to  discontinue  urethral  injections. 
From  ten  to  fifteen  vigorous  leeches  may  be  placed  upon  the  perinaeum. 


PROSTATIC   AND   PERI-PROSTATIC   AHSCESS.  209 

and  the  bleeding  be  encouraged  by  the  subsequent  application  of  hot 
water  to  the  bites.  Hot  fomentations  to  the  perinseum  and  hypogas- 
trium  tend  to  modify  ]iain.  The  skin  over  the  hypogastrium  should 
bo  kept  constantly  reddened  by  sprinkling  2)owdered  mustard  upon 
the  poultice  there  applied,  or,  more  neatly,  by  the  use  of  mustard- 
paper,  over  which  is  applied  a  flat  rubber  bag,  containing  a  thin  film 
of  very  hot  water.  If  possible,  a  general  hot  bath,  or  hip-bath,  should 
be  administered  once  or  twice  daily  or  oftcner.  Sleep  may  be  encour- 
aged at  night  by  full  doses  of  the  bromide  of  potassium,  or  sodium 
alone  or  combined  with  some  bitter  sirup  (orange-peel),  with  from 
gr.  Y_xx  chloral  hydrat.  Eepeated  rectal  examinations  of  the  prostate 
are  to  be  avoided,  and  on  no  account  should  any  instrument  be  passed 
into  the  bladder  unless  there  is  retention.  In  such  a  case  a  small 
French  olivary  catheter  should  be  gently  used,  as  seldom  as  possible 
consistently  with  comfort.  Failing  with  the  soft  instrument,  a  silver 
catheter  must  be  employed,  with  suitable  regard  to  the  inflamed  and 
tender  condition  of  the  parts.  Cases  might  occur  where  the  aspirator 
would  be  preferable  to  catheterisra. 

PROSTATIC    AND    PERI-PROSTATIC    ABSCESS.* 

If  pus  form  during  parenchymatous  inflammation  of  the  prostate, 
we  have  a  continuance,  in  a  high  degree,  of  all  the  symptoms  of  that 
inflammation,  except  that  the  local  throbbing  is  more  considerable  and 
that  the  pains  become  less  tense  and  of  a  more  lancinating  character. 
A  sharp  chill  or  a  series  of  rigors  announces  the  commencement  of  sup- 
puration. As  the  pus  forms,  it  presses  upon  the  already  narrowed 
canal  of  the  urethra,  and  finally,  unless  the  abscess  is  very  small,  ob- 
literates it  entirely,  bringing  on  retention.  There  may  be  one  or  more 
purulent  foci,  or  the  whole  substance  of  the  prostate  contained  within 
the  fibrous  capsule  may  fall  into  suppuration. 

These  abscesses,  left  alone,  discharge  into  the  urethra,  bladder,  rec- 
tum, or  through  the  perinseum.  They  are  often  tardy  in  opening 
spontaneously,  on  account  of  the  dense  nature  of  the  fibrous  capsule 
of  the  gland.  When  such  an  abscess  is  opened  or  bursts,  all  23ain  and 
discomfort  are  relieved  as  if  by  magic.  Eetention  disappears,  the  heat 
and  throbbing  cease  to  be  annoying,  and  a  continuous  flow  of  pus  is 
often  the  only  reminder  of  the  terrible  torment  which  the  patient  has 
endured.  The  pus  may  exceptionally  burrow  among  the  tissues  of  the 
perinseum,  or,  still  more  rarely,  into  the  pelvis,  giving  rise  to  local  and 
then  general  peritonitis.  In  exceptional  cases,  where  the  purulent 
focus  is  small,  it  may  never  point ;  but,  with  subsiding  inflammation, 
the  pus  may  be  gradually  absorbed,  leaving  behind  a  calcareous  mass, 

*  An  excellent  monograph  on  this  subject  is  that  of  Paul  Segond,  "  Des  Abces  chaude 
de  la  Prostate  et  du  Phlegmon  peri-pi-ostatique,"  Paris,  1880,  pp.  260. 
14 


210  DISE.^ES  OF  TEE  PROSTATE. 

of  a  size  i^roportionate  to  the  quantity  of  pus  which  it  represents. 
These  concretions  are  not  usually  discovered  till  after  death.  They 
are  rarely  of  sufficient  size  to  interfere  materially  with  tlie  contractile 
function  of  the  gland. 

After  the  pus  has  escaped  from  a  prostatic  abscess,  if  the  cavity  is 
small,  it  usually  granulates  slowly,  fills  up,  and  becomes  cicatrized  ; 
the  rapidity  of  the  process  of  repair  being  often  interfered  with,  if  not 
prevented,  by  a  communication  of  the  cavity  with  the  bladder  or  rec- 
tum— or  even  the  urethra,  from  which  urine  regurgitates  during  every 
act  of  micturition.  If  the  cavity  of  the  abscess  is  very  great,  if,  for 
example,  it  iuA'olvcs  the  whole  contents  of  the  fibrous  capsule  of  the 
prostate,  the  termination  may  be  fatal.  Sometimes  a  slow  rejiair  sets 
in,  but  it  is  rarely  if  ever  perfect.  A  small  purulent  collection  in  the 
prostate  may  empty  itself  gradually  into  the  urethra  by  a  minute  open- 
ing, and  its  existence  consequently  not  be  made  out. 

The  prognosis  in  small  abscesses  of  the  prostate  is  good,  but,  where 
the  collection  of  pus  is  very  extensive,  the  prognosis  must  be  guarded. 

Analogous  to  the  above  are  the  perijjrostatic  abscesses  which  occa- 
sionally come  on  during  the  course  of  gonorrha?a,  or  in  cases  of  strict- 
ure. Here  the  seat  of  the  purulent  collection  is  found  to  be  in  the 
connective  tissue  around  the  prostate.  The  symptoms  are,  in  the 
main,  those  of  prostatic  abscess  ;  but  they  are  less  marked,  less  intense, 
and  the  malady  is  apt  to  run  a  slower  course.  CEdema,  perceptible  to 
the  finger  in  the  rectum,  is  the  best  distinguishing  mark  between  exist- 
ing or  imminent  periiorostatic  collections  of  matter  and  abscess  within 
the  prostatic  capsule.  Such  collections  of  pus  finally  press  upon  the 
neck  of  the  bladder  and  cause  retention.  They  may  be  easily  felt  by 
the  exploring  finger  in  the  rectum,  masking  the  prostate,  and  jutting 
into  the  cavity  of  the  gut.  If  not  opened  by  the  surgeon,  they  may 
point  spontaneously  in  any  of  the  directions  named  for  prostatic  ab- 
scess, and  subsequently  behave  in  a  similar  manner. 

Periprostatic  abscess  may  sometimes  owe  its  origin  to  suppuration 
of  one  of  the  lymphatic  glands  described  by  Lannelongue  *  (six  in 
number)  lying  between  the  base  of  the  prostate  and  the  rectum.  He 
found  them  large  and  inflamed  in  a  boy  who  died  of  tuberculization 
of  the  prostate,  seminal  vesicles,  right  ureter,  and  kidneys. 

Epididymitis,  terminating  in  suppuration,  is  liable  to  complicate 
prostatic  abscess.  Abscess  of  the  prostate  rarely  leads  to  infiltration 
of  urine. 

Treatment. — With  an  abscess,  periprostatic  or  prostatic,  near  the 
posterior  wall,  whenever  fluctuation  can  be  felt  through  the  rectum, 
puncture  with  a  trocar  should  be  practiced  at  once,  to  arrest  further 
destruction  of  tissue,  to  relieve  suffering,  and  to  prevent  retention. 
Where  the  abscess  bursts  spontaneously,  the  treatment  is  purely  symp- 

*  "Bull,  de  la  Soc.  de  Chir.,"  tome  iv,  1878,  p.  600. 


FOLLICULAR  PROSTATITLS.  211 

tomatic.  "Where  the  collection  is  prostatic,  and,  Inilging  into  the  ure- 
thra, produces  retention,  without  yielding  fluctuation  through  the 
rectum,  any  of  the  three  following  courses  may  be  followed,  preferably 
the  first :  (1)  Pneumatic  aspiration  of  the  abscess  through  the  rectum  ; 
(2)  the  use  of  the  same  instrument  several  times  daily  above  the  pubes, 
to  evacuate  the  urine  waiting  for  the  abscess  to  break  ;  or  (3)  careful 
attempts  to  relieve  the  bladder  with  a  silver  catheter  joassed  through 
the  urethra.  The  abscess  is  pretty  sure  to  be  broken  during  attempts 
at  catheterism,  and  the  urine  flows  freely  immediately  after  the  pus. 

Where  a  large  cavity  in  the  prostate  is  left  behind  by  an  abscess,  it 
may  be  washed  out  daily  with  a  very  short-beaked  silver  catheter,  hav- 
ing its  eye  near  the  tip,  and,  after  the  washing,  injected  with  some 
astringent  solution  to  stimulate  granulation. 

FoLLicuLAE  Peostatitis. — In  this  disease,  the  mucous  surface  of 
the  sinus  of  the  prostate  and  of  the  mucous  follicles  and  ducts  is  in- 
flamed, while  the  substance  of  the  organ  for  the  most  part  escapes. 
The  affection  is  familiarly  known  as  prostatorrhma.  It  can  hardly  be 
said  to  exist  in  an  acute  form,  so  prone  is  it  to  run  a  chronic  course. 
It  may  come  on  during  gonorrhoea  after  the  inflammation  has  reached 
the  deeper  portions  of  the  urethra,  attended  at  first  by  symptoms  of 
parenchymatous  congestion.  The  latter  soon  subside,  and  the  prosta- 
torrhoea  alone  remains,  with  (perhaps)  some  congestion  about  the  vesi- 
cal neck,  and  consequent  irritability  of  the  bladder.  The  main  feature 
of  the  disease  is  a  slight  oozing  from  the  meatus,  muco-purulent  in 
character.  This  discharge  is  apt  to  be  more  profuse  during  the  passage 
of  hardened  fseces  through  the  rectum  at  stool.  Defecation  may  be 
painful.  The  patient  usually  believes  the  discharge  to  be  semen.  It 
does  not  contain  spermatozoa,  but  is  muco-purulent,  full  of  fatty 
debris,  leucocytes,  epithelium,  and  often  prostatic  concretions.  This 
discharge  is  exceedingly  rebellious  to  treatment. 

If,  with  follicular  prostatitis,  as  is  often  the  case,  a  certain  amount 
of  chronic  parenchymatous  inflammation  coexist,  then  we  have  an 
affection  not  common  but  exceedingly  obstinate  and  diflBcult  to  man- 
age. It  is  evidenced  by  a  combination,  in  a  mild  degi'ee,  of  the  symj)- 
toms  of  both  maladies.  A  peculiar  weight  is  felt,  dragging  down 
toward  the  perinseum,  with  painful  feelings  in  the  prostate  ;  walking 
becomes  painful ;  crossing  the  legs  decidedly  increases  the  pain,  as 
does  finally  the  sitting  posture,  and  especially  the  muscular  contrac- 
tions made  in  raising  the  body  from  the  sitting  to  the  standing  posi- 
tion, or  the  reverse. 

Added  to  these  are  symptoms  almost  identical  with  those  of  stone 
in  the  bladder.  There  is  the  same  frequency  of  urination,  less  urgent 
on  some  days  than  on  others  ;  the  urine  contains  pus  and  blood  ;  blood 
sometimes  flows  at  the  end  of  the  stream  ;  pain  is  felt  on  urination, 
both  at  the  neck  of  the  bladder  and,  especially  toward  the  close  of  the 


212  DISEASES   OF  THE   PROSTATE. 

act,  at  the  end  of  the  peuis,  along  the  under  surface  of  the  urethra ; 
the  patient  has  a  tendency  to  pull  and  tickle  the  prepuce  and  urethra  ; 
the  tender  prostate,  squeezed  at  the  end  of  urination  by  the  contract- 
ing bladder,  is  the  seat  of  extreme  sensibility.  TJie  bladder  is  liable 
to  expel  its  contents  spasmodically.  The  cut-off  muscles  of  the  mem- 
branous urethra  participate  in  the  general  irritability  of  the  part,  some- 
times interru])ting  the  stream  suddenly.  As  a  rule,  however,  this 
"ciit-off  "  does  not  come  until  near  the  end  of  the  act  of  urination, 
and  is  a  sort  of  premature  covj)  de  piston. 

"With  these  symptoms  the  patient  is  feverish  and  irritable,  unable 
to  get  about,  as  all  motion  aggravates  his  symptoms,  lie  chafes  under 
continement,  is  perhaps  listless  and  depressed  ;  perhaps  has  an  excel- 
lent appetite,  and  very  little  constitutional  disturbance.  In  chronic 
cases  the  mental  depression  is  a  feature  of  the  disease  out  of  all  pro- 
portion to  its  gravity.  A  slight  gleety  discharge  accomjianies  this  con- 
dition. It  may  escape  observation  from  the  fact  that  the  frequent 
acts  of  urination  wash  it  away  before  it  has  had  time  to  collect  suf- 
jBciently  to  show  itself  at  the  meatus.  The  finger  in  the  rectum  may 
find  slight  enlargement  and  heat  of  the  prostate,  and  at  times  detect 
extra  sensibility.  The  element  of  hyperesthesia  of  the  cut-off  muscles 
often  accompanies  and  outlasts  this  form  of  prostatic  inflammation, 
keeping  up  the  symptoms  perhaps  after  the  parts  have  returned  to  a 
nearly  normal  condition.  In  these  cases  it  is  sometimes  imi^ossible  to 
decide  that  there  is  no  stone.  Search  for  stone  should  be  instituted. 
None  will  be  found,  but  the  prostatic  urethra  will  manifest  extraordi- 
nary sensibility,  and  the  patient  will  be  much  worse  after  the  search 
than  before. 

Treatment. — In  follicular  prostatitis  no  remedy  is  so  efficacious  as 
repeated  mild  blistering  of  the  perinaeum.  It  is  best  applied  by  paint- 
ing cantharidal  collodion  upon  one  side  of  the  pcrinajum,  confining 
the  patient  for  forty-eight  hours  to  bed,  and  painting  the  other  side 
of  the  raphe,  as  soon  as  the  soreness  of  the  first  application  begins  to 
subside.  This  course,  aided  by  alkaline  diluents,  will  usually  master 
the  affection  in  a  few  weeks.  In  applying  the  collodion,  great  care 
is  necessary  to  avoid  involving  the  scrotum  and  anus,  as  the  former 
drops  over  the  blistered  portion,  while  the  serum  from  the  blister  runs 
down  over  the  latter.  This  is  best  accomplished  by  binding  the  scro- 
tum up  tightly,  and  covering  the  blistered  surface  from  the  start  with 
absorbent  cotton  and  lint,  anointing  also  the  anus  and  scrotum.  Where 
the  disease  is  of  particularly  obstinate  character,  and  of  long  duration, 
the  blisters  may  require  to  be  continued  for  many  weeks.  The  rectum 
must  be  kept  unloaded  in  chronic  prostatitis.  With  blisters  should 
also  be  combined  a  supporting  diet  and  tonics.  Bumstead  speaks 
highly  of  drachm-doses  of  dilute  phosphoric  acid  containing  a  small 
amount  of  strvchniue  in  solution.     If  the  affection  jirove  obstinate. 


TUBERCULAR  PROSTATITIS.  213 

injecting  the  membranous  urethra  with  a  mild  solution  of  nitrate  of 
silver  (gr.  v-x  to  the  ^  j)  with  the  deep  urethral  syringe  is  a  treatment 
very  often  of  the  greatest  value.  It  must  he  used  cautiously  at  inter- 
vals of  several  days. 

TuBEECULAR  PROSTATITIS. — A  form  of  chronic  prostatitis  occurs 
in  tubercular,  scrofulous,  debilitated  subjects,  the  chief  feature  of 
which  is  cheesy  degeneration,  situated  primarly  in  the  ducts  and  fol- 
licles of  the  organ.  True  miliary  tubercle  does  not  seem  to  occur  in 
the  prostate.  It  may  be  that  opportunities  of  observing  it  have  not 
presented  themselves.  The  cheesy  nodule  has  thus  far  alone  been 
found.     The  disease  is  rare. 

Tlie  symptoms  are  those  of  severe  chronic  j)rostatitis.  If  the 
cheesy  matter  be  small  in  extent,  and  situated  around  the  prostatic 
sinus  only,  it  can  not  be  diagnosticated  ;  but  if  the  same  deposit 
abound  in  the  substance  of  the  organ,  so  that  the  contour  of  the  latter 
can  be  felt  to  be  lumpy  from  the  rectum,  or,  as  is  more  commonly  the 
case,  if  the  course  of  one  or  both  vasa  deferentia  can  be  traced  out  as 
an  infiltrated  hard  tube  joined  to  a  distinctly  enlarged,  knobbed,  in- 
durated seminal  vesicle,  then  we  may  safely  assert  that  tubercular 
prostatitis  exists.  In  such  cases  one  or  both  epididymes  are  also 
usually  the  seat  of  so-called  tubercular  deposit,  and  there  may  be 
tuberculoid  foci  in  the  lungs  or  elsewhere.  Tuberculization  of  the 
prostate  not  uncommonly  follows  similar  morbid  changes  in  the  kid- 
neys, or  sometimes  precedes  it. 

The  course  of  tubercular  prostatitis  is  very  slow.  From  time  to 
time  the  symptoms  become  spontaneously  better  or  worse,  but  the 
general  tendency  is  toward  steady  aggravation.  The  cheesy  masses 
ulcerate  out,  form  abscesses  which  break  in  all  directions,  leaving  open 
cavities  or  fistulae.  Such  cavities  evince  no  tendency  to  heal.  Slight 
haemorrhage  from  the  urethra  from  time  to  time  is  a  pretty  constant 
symptom,  but  the  haemorrhage  is  followed  by  no  relief. 

Tubercle  bacilli  have  often  been  found  in  the  urine  in  cases  of  tuber- 
cular disease  of  the  urinary  tract.  They  are  difficult  to  detect.  A  thick- 
ish  portion  of  sediment  must  be  used.  A  portion  of  this  is  crushed 
between  two  thin  microscopic  cover-glasses  and  caused  to  adhere  by 
being  passed  rapidly  a  few  times  through  the  flame  of  an  alcohol 
lamp  or  Bunsen  burner.  A  modification  of  the  Weigert-Ehrlich 
method,  introduced  by  Tolman  *  of  Chicago,  is  easy  of  application  and 
quicker  than  the  original  method.     Make  two  solutions  : 

1.  Aniline  oil,  tti,  xxx  ;  distilled  water,  §  lij.  Mix  and  shake 
thoroughly,  then  filter. 

2.  Saturated  solution  of  fuchsine  in  commercial  alcohol,  93  per 
cent. 

Take  of  No.  1  3  ij,  and  of  No.  3  ni  xv,  and  mix.     Heat  this  to 
*  "  The  Medical  Record,"  Oct.  23,  1886,  p.  457- 


214  DISEASES  OF  THE   PROSTATE. 

50°  C.  (122°  F.),  and  drop  the  cover-glass  upon  it,  film  of  pus  down- 
ward, allowing  it  to  remain  one  hour.  Then  wash  the  cover-glass  in 
pure  water  and  decolorize  with  a  33-per-eent  solution  of  nitric  acid 
until  the  film  of  pus  ajjpears  nearly  without  color.  Wash  again  in 
water.  If  the  red  color  reappears,  the  process  has  been  effected.  If 
the  red  color  does  not  apjioar,  then  the  specimen  lias  been  too 
long  in  the  nitric  acid.  Double  staining  is  not  necessary  for  a  general 
examination.  Mount  in  glycerin  and  exaniiiie  witli  a  high  i)owcr — 
better  with  an  immersion  lens. 

Prog7iosis  is  bad.  Death  occurs  from  the  gradual  running  down 
of  the  patient,  or  from  tubercular  disease  elsewhere  ;  the  latter,  per- 
haps, being  of  the  true  miliary  type.  Occasionally  recoveries  are 
made  under  the  continued  efficient  action  of  hygienic  conditions 
and  proper  food.  The  course  of  the  malady  is  always  exceedingly 
slow. 

Treatment. — Curative  treatment  consists  of  general  rather  than 
local  means.  For  local  treatment,  the  same  rules  apply  here  as  those 
laid  down  for  chronic  follicular  prostatitis.  The  general  measures  are 
hygiene,  fatty  food,  tonics,  projDer  clothing,  life  out  of  doors,  travel- 
ing, change  of  climate,  anti-strumous  medication.  These  means,  in- 
telligently combined,  sometimes  effect  a  cure. 

CANCER   OF   THE   PROSTATE. 

Primary  cancer  of  the  prostate  is  exceedingly  rare.  More  usually 
it  is  secondary  to  advanced  malignant  disease  elsewhere — especially 
in  the  kidney  or  testicle.  As  to  the  relative  frequency  of  this  disease, 
Tanchou,*  out  of  8,289  cases  of  fatal  cancer,  sets  down  only  three  for 
the  prostate.  Scirrhous,  melanotic,  and  medullary  disease,  have  all 
been  noted  ;  the  latter  most  frequently.  Cancer  occurs  chiefly  in  ad- 
vanced life,  sometimes  as  a  complication  of  already  existing  hyper- 
trophy, and  doubtless  some  of  these  cases  have  not  been  recognized. 
Medullary  cancer,  as  a  primary  affection,  has  been  observed  in  the 
prostate  of  young  children,  f  Pitha  saw  one  fatal  case  in  a  stout  man 
of  thirty. 

Symjjtoms. — The  symptoms  of  cancer  of  the  prostate  are  at  first 
simply  those  caused  by  the  increased  size  of  the  organ,  obstruction  to 
urination,  frequency  of  the  act,  and  pain.  Increase  in  size  does  not 
occur  as  rapidly,  or  with  as  acute  symptoms,  as  does  inflammatory  en- 
largement ;  but  more  painfully  and  more  rapidly  than  senile  hyper- 
trophy. When  cancer  becomes  engrafted  upon  an  hypertrophied 
prostate,  its  diagnosis  during  the  early  stages  is  impossible.     The 

*  Quoted  by  Pitha,  op.  cit. 

f  Jullien's  article  "  Prostate,"  in  "  Diet.  Prat,  de  Med.  et  de  Chir.,"  is  full  of  informa- 
tion on  the  subject  of  cancer. 


CANCER  OF  THE   TRORTATE.  215 

diagnosis  with  liydatids  or  cysts  (diluted  follicles — of  quite  common 
occurrence,  but  of  no  pathological  importance)  is  made  by  the  prog- 
ress of  the  affection.  The  symptoms,  then,  of  cancer  of  the  prostate 
are  not  pathognomonic  at  first,  but  there  are  certain  important  aids 
to  correct  diagnosis.  Thus,  if  the  affection  be  scirrhus,  the  peculiar 
hardness  will  be  significant ;  if  medullary  cancer,  the  enlargement  felt 
through  the  rectum  is  usually  less  uniform  than  in  hypertrophy,  and 
certain  spots  may  often  be  felt  softer  than  others,  sometimes  amount- 
ing to  a  feeling  of  deep  fluctuation.  The  i)ain  on  pressure  by  the 
rectum  is  less  decided  than  in  inflammation,  but  more  positive  than  in 
hypertrophy.  Tlie  glands  in  the  pelvis  and  in  the  groin  sooner  or 
later  enlarge,  and  assume  cancerous  characters.  Hence  the  existence 
of  obscure  swellings  along  the  course  of  the  iliac  vessels,  felt  through 
the  abdomen,  is  an  important  aid  to  diagnosis.  Cancerous  cachexia 
is  slow  to  appear.  Its  presence  clears  up  any  doubts  which  may  have 
existed. 

Cancer  of  the  prostate  is  not  propagated  from  the  bladder.  I  am 
not  aware  of  any  reported  instance  in  which  such  propagation  has 
been  observed.  It  does  propagate  itself  from  the  prostate  to  the 
bladder,  and  two  instances  are  on  record  (Bennett,  Cushing)  where 
cancer  of  the  rectum  has  secondarily  invaded  the  prostate. 

The  importance  of  the  existence  of  cancerous  growths  elsewhere  is 
evident,  and  especially  is  this  true  of  cancer  of  the  testicle  or  kidney. 
The  pain  felt  in  cancer  of  the  prostate  is  noticed  largely  in  the  rectum 
and  about  the  sacrum,  or  radiating  into  the  back,  or  down  the  thighs. 
Hsemorrhage  from  the  urethra  is  a  symptom  liable  to  appear  both 
early  and  late  in  this  affection.  The  blood  flows  freely,  is  arterial  in 
character,  and  often  excessive  in  amount.  It  may  appear  spontane- 
ously, or,  more  frequently,  during  urination.  A  certain  amount  of 
relief  to  the  symptoms  is  apt  to  follow  such  hsemorrhage.  The  urine 
is  turbid,  purulent,  often  containing  considerable  debris  of  tissue. 
Sometimes  a  shred  of  tissue  of  considerable  size  is  passed,  or  j^ulled 
away  in  the  eye  of  a  catheter.  From  such  a  shred  a  diagnosis  of  can- 
cer can  sometimes  be  made  by  the  microscope.  Diagnosis  based  on 
finding  so-called  cancer-cells  in  the  urine  is  entirely  unreliable.  Re- 
tention is  apt  to  occur  from  obliteration  of  the  prostatic  urethra  by 
cancerous  growth.  In  such  cases  catheterization  is  difficult  and  ex- 
ceedingly painful,  while  the  operation  is  pretty  sure  to  provoke  con- 
siderable bleeding.  Hypertrophy  of  the  bladder  with  dilatation,  and 
perhaps  stone,  may  come  on,  as  in  other  obstructive  prostatic  disease. 
The  duration  of  the  disease  is  set  down,  from  first  appearance  of 
symptoms  to  fatal  termination,  at  from  one  and  a  half  to  five  years  for 
adults,  three  to  nine  months  for  children. 

Treatment. — This  is  symptomatic,  and  consists  in  the  careful  em- 
ployment of  the  catheter,  if  required,  even  the  establishment  of  a 


216  DISEASES   OF  THE   PROSTATE. 

permanent  ojiening  above  the  pubes,  with  alkaline  diluents,  tonics, 
and  anodynes  in  suppository  and  by  the  stomach.  Patients  do  not 
recover  from  this  disease.  The  prostate  has  been  surgically  extirpated 
with  a  portion  of  the  lloor  of  the  bladder  and  the  rectal  wall,  but  the 
operation  is  not  to  be  justified  by  any  results  yet  attained.  Permanent 
drainage  through  the  pcrinajum  is  not  suitable  in  these  cases  as  a 
rule. 

Simple  cysts  in  the  prostate  are  not  uncommon  ;  hydatids  are 
rare.* 

PROSTATIC   CONCRETIONS. 

The  adult  prostate  and  portions  of  the  neighboring  urethra  contain 
certain  bodies  called  prostatic  concretions.  Eobin  and  Oadiat  state 
that  Virchow  discovered  similar  bodies  in  the  female  urethra.  They 
are  visible  with  the  microscope  at  any  time  after  puberty,  but  do 
not  attain  considerable  size  until  adult  or  advanced  age.  Thompson 
has  described  them  minutely.  They  are  not  to  be  confounded  with 
stone  of  urinary  formation.  They  are  often  found  of  very  small 
size  in  the  voided  urine.  In  such  cases  they  have  no  jiathological 
significance.  During  their  forming  stage  (when  they  measure  from 
the  one-thousandth  to  the  one-hundredth  of  an  inch)  they  appear 
under  the  microscope  of  an  oval  or  slightly  angular  form,  of  pearly 
luster,  and  in  varying  shades  of  light-yellow  color.  Tiiis  color  in- 
creases in  the  larger  concretions  to  a  deep  orange.  They  have  a  cel- 
lular appearance,  but  no  nucleus,  and,  as  they  become  larger,  exhibit 
concentric  rings  of  different  thickness.  Often,  in  the  larger  concre- 
tions, many  of  the  smaller  bodies  seem  to  have  been  lying  together, 
and  to  have  become  surrounded  by  concentric  layers  of  yellowish 
material  to  form  one  mass.  Often,  lines  are  seen  radiating  from  the 
center  toward  the  circumference,  and  in  the  direction  of  these  lines 
cleavage  takes  place  when  the  masses  are  subjected  to  pressure.  When 
young  they  arc  very  soft,  but,  as  they  increase  in  size,  they  become 
exceedingly  hard  and  stony.  The  young  cell-like  bodies  are  not 
affected  by  acids,  or  alkalies,  or  ether  ;  but  the  larger  dark  bodies  are 
rendered  somewhat  more  translucent  by  alkalies,  while  the  mineral 
acids  (especially  sulphuric)  usually  occasion  liberation  of  bubbles  of 
gas  (carbonic  acid)  and  some  shrinkage  in  size,  sometimes  disintegrat- 
ing them  into  a  mass  of  amorphous  matter,  which  still  retains  its 
color  and  bulk.  Hot  nitric  acid  dissolves  them,  producing  a  faint 
yellow  color. 

The  larger  concretions  consist  of  a  protein  substance,  with  phos- 
phate and  carbonate  of  line.  They  are  often  found,  visible  to  the 
naked  eye,  in  the  urethra,  around  the  veru  montanum,  chiefly  after 
the  age  of  fifty.    It  may  be  necessary  to  make  a  section  of  the  jirostate 

*  Consult  llauxion,  "Des  Kystes  de  la  Prostate,"  "  These  127,"  Paris,  1878. 


rROSTATIC  CONCRETIONS.  217 

to  find  them,  placing  the  milky  fluid  scraped  from  the  cut  surface 
under  the  microscope.  In  one  case  Thompson  estimated  the  number 
to  be  seen  by  the  naked  eye  as  amounting  to  several  thousands.  These 
bodies  occupy,  anatomically,  the  ducts  and  follicles  of  the  secreting 
structure  of  the  prostate.  The  earthy  salts  are  added  to  them  as  they 
grow.  They  sometimes  attain  the  size  of  a  pea  or  small  nut.  As  they 
enlarge  by  new  accretions  upon  their  circumference,  they  press  upon 
and  cause  the  absorption  of  the  duct  or  follicle  in  which  they  origi- 
nated, and  several  of  them  may  be  found  adhering  to  each  other  in  a 
single  sac  or  cyst. 

From  the  above  description  it  may  be  gathered  that  these  concre- 
tions resemble  salivary  or  biliary  concretions  rather  than  true  stone. 
When  they  become  large  enough  to  constitute  sources  of  irritation, 
dense,  opaque,  earthy  matter  deposits  upon  them,  and  they  then  be- 
come true  prostatic  calculi,  and  may  go  on  indefinitely  increasing  in 
size.  These  prostatic  calculi  are  met  with  of  all  sizes  and  shapes. 
Several  of  them  may  be  found  separated  from  each  other,  perhaj^s 
imbedded  in  cysts,  which  are  dilated  follicles,  or,  if  many  of  them  are 
present,  causing  atrophy  of  prostatic  substance,  until  the  prostate 
resembles  a  sack  full  of  small  stones,  which  may  be  felt  rubbing  against 
each  other  on  pressure  per  rectum,  giving  an  emphysematous-like 
crackling  (Adams).  In  bad  cases,  prostatic  calculi  tend  to  unite,  pro- 
jecting into  the  urethra,  and  forming  curiously  distorted,  branched 
masses,  dipping  down  into  the  substance  of  the  prostate,  and  extending 
forward  into  the  canal  of  the  urethra,  and  backward  perhaps  into  the 
bladder.  Such  masses  have  been  found  four  or  five  inches  long.  One, 
removed  by  T.  Herbert  Barker,  is  referred  to  by  Thompson  as  being 
composed  of  nine  portions,  weighing,  collectively,  three  ounces,  four 
drachms,  and  one  grain. 

■  Prostatic  stones  are  exceedingly  hard,  and  have  a  polished  surface. 
They  may  be  brilliantly  white,  resembling  porcelain,  or  of  a  fawn  or 
pale-brown  color.  They  are  composed  mainly  of  phosphate  of  lime, 
with  a  small  admixture  (derived  from  the  urine)  of  the  triple  (am- 
monio-magnesian)  phosphate.  They  very  rarely  give  trouble  during 
life,  but  when  of  large  size  they  may  give  rise  to  all  the  symptoms  of 
prostatic  obstruction,  in  an  aggravated  form,  leading,  in  the  same 
manner,  to  chronic  cystitis,  hypertrophy,  and  sacculation  of  the  blad- 
der. "When  these  calculi  project  into  the  urethra,  a  metallic  instru- 
ment, introduced  into  the  bladder,  may  be  felt  to  grate  ujjon  them  in 
passing. 

Treatment. — The  natural  mode  of  elimination  of  these  masses  is  by 
the  formation  of  abscess.  They  may  ulcerate  out  through  the  rectum, 
or  perin^eum,  or  into  the  urethra,  or  even  into  the  bladder.  Stone  in 
the  bladder  not  uncommonly  coexists  with  them.  When  they  become 
large  enough  to  give  rise  to  distressing  symptoms,  an  attempt  may  be 


213  DISE.VSES  OF  THE  BLADDER. 

made  to  remove  them  with  tlie  long  urethral  forceps  (Brodie),  but  the 
best  method  is  to  cut  down  through  the  perinamm  in  the  median  line, 
and  extract  everything  of  a  calculous  nature  which  can  be  found.  If 
any  portion  be  left  it  becomes  at  once  a  nucleus  for  further  incrusta- 
tion. During  such  an  operation  the  bladder  should  always  be  searched 
for  stone.  In  exceptional  cases,  where  prostatic  stones  can  be  felt  in 
the  substance  of  the  prostate  through  the  rectum,  an  incision  may  be 
made  through  the  Avails  of  the  latter,  and  their  removal  thus  elTected. 
Certain  concretions  found  in  the  dilated  veins  around  an  old  prostate 
and  known  as  phleboliths,  must  not  be  confounded  with  prostatic  cal- 
culi. They  are  not  infrequently  detected  after  death,  and  are  small 
white  or  colored  smooth  bodies,  perhaps  as  large  as  a  pea,  such  as  are 
formed  in  dilated  veins  elsewhere.  The  calcareous  remains  of  old 
abscesses  which  have  been  absorbed,  and  which  in  rare  instances  are 
found  in  the  prostate,  must  not  be  confounded  with  calculi.  Finalh', 
a  true  urinary  calculus  may  become  lodged  in  the  i)rostatic  sinus  when 
small,  and  continue  to  grow  there  by  deposits  of  urinary  salts,  causing 
absorption  of  prostatic  tissue,  and  finally  becoming  imbedded  in  that 
organ  (Meckel,  Adams).  Such  stones  may  grow  backward  into  the 
bladder  (prostato-vesical  calculi,  Yidal),  or  true  stone  in  the  bladder, 
becoming  attached  near  the  neck  of  the  latter,  may  grow  forward  into 
the  prostatic  urethra  (vesico-prostatic  calculus). 

Syphilis  of  the  Prostate. — Although  it  is  possible  for  syphilis 
to  cause  its  peculiar  deposit  in  the  prostate,  yet  it  rarely,  if  ever,  does 
so.  There  is  certainly  no  syphilitic  condition  of  the  prostate  which 
can  be  diagnosticated  by  any  symptoms  that  I  can  name. 


CHAPTER  XII. 
DISEASES  OF  THE  BLADDER. 

Anatomy.— Anomalies  and  Deformities,  Exstrophy.— nernia  of  Bladder.— Hypertrophy.— Atrophy, 
—Wounds.— Kuptiire  of  the  Bladder.— Foreign  Bodies.— Retention  of  Urine.— Incontinence  :  in 
Children,  in  Adults. — Tenesmus.— Chorea.— Hsematuria.— Neuralgia  of  tlie  Vesical  Neck. — 
Cause. — Symptoms. — Diagnosis. — Treatment. 

Anatomy. — The  bladder  is  a  muscular  sac  lying,  in  the  male,  be- 
tween the  rectum  and  pubes  when  empty,  and  distending,  when  full, 
into  an  oval  bag  occupying  more  or  less  of  the  hypogastrium.  Its 
position  is  fixed  below  by  the  urethra,  but  mainly  by  the  pelvic  fascia, 
which,  after  having  lined  the  cavity  of  the  true  pelvis,  is  reflected 
upward  and  lost;  on  the  bladder  and  rectum  (as  pubo-prostatic  and 
inferior  vesical  ligaments),  and  the  recto-vesical  fascia  which  binds  the 
prostate  and  neck  of  the  bladder  to  the  rectum.     Above  and  on  the 


ANATOMY   OF   THE   J3LADDER.  219 

sides  the  peritonaeum  covers  the  bladder,  but  is  attached  loosely,  espe- 
cially at  the  base,  so  as  to  offer  no  obstacle  to  any  change  in  shape  or 
position  of  the  viscus.  A  knowledge  of  the  reflections  of  the  perito- 
nseum  upon  the  bladder  is  essential  to  a  correct  understanding  of  the 
methods  of  relieving  retention  by  puncture.  AVhen  the  bladder  is 
empty,  it  lies  contracted  behind  the  pubes  ;  the  peritonoeum  leaves  the 
abdominal  walls  at  the  symphysis,  and  passes  at  once  to  the  bladder, 
over  which  it  is  spread,  and  then  reflected  upon  the  rectum  from  the 
base  of  the  bladder,  so  that,  when  the  latter  is  absolutely  contracted 
upon  itself,  that  portion  of  its  base  lying  between  the  seminal  vesicles 
is  also  covered  by  peritonseum,  and  there  is,  properly  speaking,  no 
direct  relation  between  the  bladder  and  rectum.  Yery  different,  how- 
ever, is  the  condition  when  the  viscus  is  distended.  Then,  as  its  cavity 
fills  up,  the  peritonasum  is  carried  with  it.  The  recto-vesical  cul-de- 
sac  of  the  peritonseum  is  deepened,  and  all  that  portion  of  the  base  of 
the  bladder  situated  between  the  seminal  vesicles  lies  directly  in  con- 
tact with  the  rectum.  When  the  bladder  is  greatly  distended,  its  base 
becomes  thus  uncovered  for  a  distance,  roughly  estimated,  of  two  inches 
behind  the  posterior  margin  of  the  prostate.  In  the  same  way  the 
distended  bladder  carries  up  the  peritonaeum  in  front,  so  that  a  dis- 
tance of  one  to  two  inches,  or  even  more,  above  the  symphysis  becomes 
bare  of  peritonaeum  in  extreme  retention.  Hence  the  election  of  these 
two  uncovered  spots  for  puncture. 

The  medium  capacity  of  the  adult  bladder  is  eight  ounces,  subject 
to  extensive  variations  from  habit  or  disease.  The  bladder  may  become 
so  contracted  as  to  contain  only  a  few  drachms,  or  again  capable  of 
holding,  without  rupture,  the  better  part  of  a  gallon. 

The  muscular  coat  of  the  bladder  is  composed  of  a  set  of  external 
fibers  which  run  mainly  longitudinally,  some  of  them  being  continued 
up  the  urachus,  and  an  internal  set  whose  general  direction  is  circular. 
These  latter,  greatly  re-enforced  in  number,  encircle  the  neck  of  the 
bladder  and  internal  orifice  of  the  urethra,  and  pass  under  the  general 
name  of  sphincter  of  the  bladder.  Certain  fibers,  running  across  the 
base  of  the  trigonum  Lieutaudii,  serve  to  pull  upon  and  open  the 
mouths  of  the  ureters. 

The  mucous  membrane  of  the  bladder  is  of  a  pale  salmon  color,  re- 
markably insensitive  in  health,  covered  by  a  stratified  pavement  epi- 
thelium, and  lying  in  folds  when  the  bladder  is  contracted.  The 
glands  are  not  numerous,  except  on  the  trigone  and  near  the  neck. 
Their  ofiice  is  to  secrete  lubricating  mucus.  They  are  exceedingly 
small,  and  composed  of  simple  clusters  of  follicles.  The  coats  of  the 
bladder  are  united  by  connective  tissue  which  is  everywhere  loose, 
except  at  the  trigone. 

The  Yesical  arteries  come  from  the  hypogastric.  The  veins  termi- 
nate in  a  thick  plexus  about  the  prostate  and  sides  of  the  base  of  the 


220  DISEASES   OF   THE   BLADDER. 

bladder,  emptying  llnally  into  the  hypogastric  veins.  The  lymphatics 
lead  to  the  hypogastric  ganglia.  The  nerves,  partly  sympathetic  and 
partly  sj^inal,  come  from  the  hypogastric  plexus. 

The  neck  of  the  bhulder  is  tliat  jiortion  surrounded  by  the  sphincter 
and  base  of  the  prostate,  limited  anteriorly  by  the  ridge,  more  or  less 
prominent  in  the  adult,  wliicji  maps  out  the  posterior  limit  of  the  pros- 
tatic sinus. 

Tlie  trigone  (of  Lieutaud)  is  a  triangular  space  lying  between  the 
neck  of  the  bladder  and  the  orifices  of  the  ureters.  The  muscular  coat 
is  here  transverse,  thick,  adherent  to  the  mucous  membrane.  Its  pos- 
terior margin  is  limited  by  a  more  or  less  prominent  ridge  running 
between  tiie  mouths  of  the  ureters.  The  ridge  can  be  followed  along 
by  the  prominence  made  by  the  ureters  as  they  penetrate  obliquely  the 
muscular  coats  of  the  bladder. 

The  *'bas-fond''  of  the  bladder  exists  only  after  middle  life,  and  is 
that  part  of  the  base  of  the  organ  lying  behind  the  posterior  ridge  of 
the  trigone.  When  the  bladder  is  distended  in  later  life,  this  portion 
lies  on  a  lower  level  than  the  trigone. 

The  uraclius  is  the  remains  of  the  allantoid  prolongation.  It  often 
remains  02)cu  for  a  short  distance  above  the  vertex  of  the  bladder  and 
sometimes  continues  pervious  throughout,  so  that,  in  adult  life,  the 
urine  still  passes  by  the  navel,  but  this  is  exceedingly  rare. 

The  bladder  in  the  fa>tus  and  in  early  life  is  an  abdominal  organ, 
situated  mainly  above  the  pubes.  As  the  pelvis  enlarges  it  settles  down 
behind  the  symphysis,  and  only  rises  into  the  abdomen  when  distended. 
The  mucous  membrane  of  the  healthy  bladder  is  less  capable  of  absorp- 
tion than  any  other.*  "When  deprived  of  its  epithelium,  absorption 
goes  on  as  from  otlier  nude  surfaces. 

ANOMALIES    AND    DEFORMITIES    OF    THE    BLADDER, 

The  bladder  is  almost  invariably  unique.  Large  sacculi  have  some- 
times been  described  as  supernumerary  bladders,  and  they  may  indeed 
reach  a  size  double  or  triple  that  of  the  bladder  itself.  They  may 
always  be  recognized  by  being  destitute  of  muscular  covering.  They 
are  herniae  of  the  mucous  coat  through  the  meshes  of  the  muscular 
tunic.  Molinetti  f  describes  a  woman  who  had  five  kidneys,  five  blad- 
ders, and  six  ureters.  Partial  partitions  extending  into  the  bladder 
have  been  observed.  Blasius  f  relates  a  case  of  perfect  segmentation 
of  the  bladder  by  a  partition,  one  ureter  opening  on  each  side.  Po- 
drazki  X  refers  to  several  cases  by  different  authors.     The  bladder  is 

*  Excellent  article  by  Mass  and  O'Pinner,  "  Centralblatt  f.  mcd.  Wissnschft.,"  Decem- 
ber 11,  1881. 

\  Quoted  by  Pitha. 

X  "Die  Krankheiten  des  Penis  und  dor  Harnblasc,"  p.  51,  Erlangcn,  1871. 


EXSTROPUY.  221 

sometimes  abnormally  small,  occasionally  wanting,  in  which  case  the 
ureters  may  open  directly  into  the  urethra  or  into  the  rectum,  or  into 
a  general  cloaca,  there  being  at  the  same  time  arrest  in  the  develop- 
ment of  other  portions  of  the  genital  apparatus.  Besides  the  above, 
there  is  one  deformity,  exstrophy,  the  occurrence  of  which  is  suffi- 
ciently common  to  demand  a  special  description. 

ExsTKOPHY  OF  THE  Bladdek. — This  deformity  is  found  in  both 
sexes,  but  much  more  frequently  in  the  male.*  In  the  female  it  is  of 
less  importance,  as  it  may  be  more  easily  concealed,  and  docs  not  pre- 
vent the  performance  of  the  sexual  act.  Cases  of  j)regnancy  and  suc- 
cessful delivery  at  term  are  recorded.  The  subject  will  be  considered 
here,  however,  only  in  relation  to  the  male. 

The  deformity  is  an  arrest  of  development  in  the  median  line,  anal- 
ogous to  hare-lip,  and  is  found  in  different  degrees.  In  a  type  case 
the  lower  part  of  the  front  wall  of  the  abdomen  and  the  front  wall  of 
the  bladder  are  absent.  The  pubic  bones  are  more  or  less  widely  sep- 
arated from  each  other,  their  ends  being  united  by  a  strong  band  of 
fibrous  tissue.  The  posterior  wall  of  the  bladder,  pressed  out  by  the 
intestines,  forms  a  mottled,  red,  tomato-like  tumor,  occupying  the 
position  of  the  symphysis  pubis.  Inguinal  hernia  of  one  or  both  sides 
is  not  uncommonly  present,  either  partial  or  extending  down  into  the 
scrotum,  which  is  usually  normal,  containing  the  testicles.  The  penis 
is  more  or  less  rudimentary,  and  affected  by  complete  epispadias.  The 
ureters  are  sometimes  greatly  dilated,  forming,  as  it  were,  rudimentary 
bladders.     A  good  illustrative  case  is  figured  by  Sir  Astley  Cooper,  f 

The  above  description  applies  to  a  type  case.  There  may  be  varia- 
tions in  the  absence  of  herniae,  a  normal  union  of  the  pubic  bones,  the 
amount  of  the  protrusion,  etc.  Ordinarily  in  the  adult  the  mass 
reaches  the  size  of  the  palm.  "With  comjDlete  exstrophy  there  is  also 
always  complete  epispadias.  A  condition  analogous  to  exstrojahy  may 
exist  where  the  bony  union  of  the  pelvis  is  lacking,  but  the  anterior 
walls  of  the  abdomen  and  bladder  are  perfect.  Here  there  is  a  sort  of 
hernia  of  the  bladder  forward.  In  such  cases  there  is  always  some 
anomalous  condition  of  the  external  organs  of  generation. 

In  exstrophy  of  the  bladder,  the  patient's  condition  is  miserable 
indeed.  The  thickened  inflamed  mucous  membrane  covering  the  pro- 
truded posterior  wall  of  the  everted  bladder  is  constantly  covered  by 
decomposing  '^ stringy  mucus"  of  alkaline  reaction,  similar  to  what 
is  found  in  vesical  catarrh.  From  the  orifices  of  the  ureters,  which 
can  be  readily  seen  by  pressing  back  the  protruded  mass,  there  con- 

*  Mr.  Earle  ("  London  Medical  and  Surgical  Journal,"  vol.  i)  alludes  to  sixty-eight 
reported  cases,  of  which  sixty  were  male.  Isidore  Geoffroy  St.-Hilaire  ("  Histoire  g^ne- 
rale  et  particuliere  des  Anomalies  de  I'Organisation  chez  I'Homme  et  les  Animaus,"  Paris, 
1825)  estimates  that  one  fourth  of  the  cases  are  female. 

f  "  Edinburgh  Medical  and  Surgical  Journal,"  vol.  i. 


222  DISEASES   OF   THE   BLADDER. 

sttiutly  distills  a  limpid,  acid,  lioallhy  urine.  This  at  once  becomes 
alkalinized  by  contact  with  the  inflamed  mucous  surface  of  the  blad- 
der, and  goes  into  rapid  decomjio^^ition,  wetting  the  patient's  linen  and 
keeping  him  constantly  surrounded  by  an  atmosphere  of  amnioniacal, 
fetid  gases,  making  him  disgusting  to  himself  and  intolerable  to  his 
friends.  The  integument  of  the  abdomen  and  thighs  becomes  excori- 
ated and  inflamed.  The  friction  of  garments  in  Avalking  only  serves 
to  aggravate  the  existing  difficulties,  and  the  sufferer  is  in  a  condition 
truly  pitiable. 

.  By  pressing  back  the  inllanicd  bladder  a  small  prostate  is  exposed, 
lying  at  the  angle  of  the  penis  and  the  vesical  tumor,  and  upon  it  the 
veru  montanum  and  ejaculatory  ducts  may  be  plainly  seen.  These 
patients  have  erotic  fancies  and  seminal  emissions ;  but  they  are  in- 
capable of  full  erection  or  of  perfect  sexual  intercourse. 

Patients  with  exstrophy  of  the  bladder  have  been  useful  to  science 
in  facilitating  experiments  upon  the  rapidity  of  the  appearance  in  the 
uriue  of  substances  taken  into  the  stomach.  Thus  it  has  been  found 
that  asparagus  aifects  the  urine  in  eight  and  a  half,  turpentine  in  four 
and  a  half  minutes,  etc.  (salts  much  more  quickly).  Furthermore,  thoy 
give  positive  evidence  of  the  fact  that  the  secretions  forming  on  the 
surface  of  an  inflamed  bladder  are  alkaline,  and  that  the  urine  coming 
down  healthily  acid  from  the  kidneys  is  at  once  alkalinized  on  reach- 
ing the  bladder  and  promptly  decomposed.  Hence  the  rule  to  give 
alkalies  to  correct  alkaline  uriue  where  such  alkalinity  is  due  to  blad- 
der inflammation,  since  by  this  means  the  urine  is  rendered  less  acid 
and  less  irritating  as  it  comes  from  the  kidney. 

Treatment. — Attempts  (Sonnenburg)  to  destroy  the  mucous  mem- 
brane by  cauterization,  and  leave  cicatricial  tissue  in  its  place,  usually 
prove  unsatisfactory.  Plastic  operations  have  been  performed  with 
sufficient  success  (five  per  cent  mortality)  to  be  Justifiable  if  the  patient 
will  take  tlie  risk  of  a  fatal  termination  to  an  operation  undertaken  to 
relieve  a  deformity  which  does  not  threaten  life.  Usually  several  op- 
erations are  necessary  to  reduce  the  aperture  to  a  small  size  ;  but,  even 
wdien  the  flaps  slough,  the  subsequent  contraction  of  the  cicatrix  is 
said  to  improve  the  local  condition.  If  an  operation  is  to  be  per- 
formed, each  case  forms  a  study  by  itself.  Usually  a  large  abdominal 
flap  is  dissected  up  from  above  the  tumor  and  turned  down  over  it, 
epithelium  inward.  The  raw  external  surface  of  this  flap  is  covered 
by  one  or  more  side-flaps  or  by  integument  taken  from  the  thigh  ;  such 
flap  or  flaps  are  secured  in  place  over  the  abdominal  flap  by  bringing 
the  raw  surfaces  into  contact,  and  fixing  the  whole  by  sutures.  Some 
sloughing  is  to  be  anticipated,  and  subsequent  operations  have  to  be 
devised  to  meet  the  requirements  of  special  cases.  The  most  that  can 
be  done  is  to  inclose  the  bladder,  leaving  an  opening  below,  through 
which  the  urine  flows  unrestrained,  as  it  is  impossible  to  reproduce  a 


EXSTROPHY— TREATMENT.  223 

sphincter.  Finally,  a  suitable  urinal  is  adjusted  and  worn  constantly. 
Hairs  should  be  removed  by  electrolysis  from  any  ilsbii  which  it  is  pro- 
posed to  turn  inward,  or  they  will  grow  and  give  trouble  later  on. 

John  Wood  *  reports  a  case  which  seems  to  be  an  exceedingly  good 
example  of  what  may  be  effected.  A  boy  seven  years  old  was  operated 
upon  four  times,  and  the  bladder  was  closed  in — all  but  a  small  hole 
large  enough  to  admit  the  little  finger.  The  patient  was  able  to  retain 
two  ounces  of  urine,  but  any  cough  or  other  contractile  effort  would 
expel  it  in  a  jet.  Pancoast,f  of  Philadelphia,  was  the  first  surgeon 
•who  operated  upon  this  condition,  and  the  names  of  Ayres,  J  of  Brook- 
lyn, and  Maury,*  of  Philadelphia,  are  favorably  known  in  connection 
with  it ;  but  much  of  interest  has  been  contributed  by  Vrolick,  J. 
Miiller,  Steiner,  Heydenreich,  Trendelenburg,  John  Wood,  and  others. 

The  most  that  can  be  promised  by  an  operation  is  that  the  mucous 
membrane  shall  be  shut  in,  and  a  cavity  furnished  which  shall  hold 
a  little  urine.     A  urinal  must  still  be  worn — at  least  by  day. 

Yet  even  this  shutting  in  of  the  raw  surface  affords  the  patient 
great  comfort,  and  justifies  an  operation.  Sometimes  a  very  simple 
procedure  suffices.  Thus  Wyman,||  of  Detroit,  reports  a  successful 
operation  upon  a  child  of  five  years  by  simply  paring  the  edges  broadly 
and  uniting  with  hare-lip  pins  and  superficial  sutures,  making  liberat- 
ing incisions  on  each  side.  Kead  ^  cured  an  extroversion  through  the 
umbilicus  in  the  same  way.  An  excellent  method  seems  to  be  that 
devised  by  Thiersch,  of  Leipsic.  MacCormac  ^  has  reported  a  success- 
ful case  so  operated  on.  One  or  two  lateral  flaps  are  cut  very  broad 
and  one  third  longer  than  the  gaj)  they  are  to  cover.  They  are  left 
attached  at  each  end  with  oiled  lint  beneath  them  until  they  have 
thickened  up,  become  very  vascular,  and  granulated  beneath.  After 
three  weeks  the  flap  (for  only  one  is  moved  at  a  time)  is  cut  at  its 
upper  end,  and  swung  around  into  position.  There  is  no  difficulty 
about  hairs  here,  the  flap  is  sure  to  live,  and  success  is  certain  so  far 
as  any  operation  can  be  successful.  Both  Thiersch  and  MacCormac 
agree  that  it  takes  a  year  to  complete  a  case. 

When  an  operation  is  declined,  a  suitable  urinal  may  be  adapted  to 
the  parts  as  left  by  Nature — such  a  one  as  shall  shield  them  from  injury, 
and  keep  the  patient  dry  and  clean.  A  urinal  of  this  sort  exists,  and 
about  a  dozen  patients  in  the  United  States,  male  and  female,  have 
attested  its  sufficiency  for  all  practical  purposes.  It  was  originated 
by  Mr.  Earle,  of  St.  Bartholomew's  Hospital.     It  is  figured  by  Vro- 

*  "Med.  Times  and  Gaz.,"  1865,  vol.  i,  p.  115. 

f  "North  American  Mcd.-Chir.  Review,"  July,  1859. 
X  "Am.  Med.  Gaz.,"  February,  1859. 

#  "Am.  Journ.  Med.  Sci.,"  July,  1871. 

II  "  Medical  Record,"  December  12,  1885,  p.  646. 

^  "Annals  of  Anat.  and  Surg.,"  June,  1882,  p.  211. 

^  "St.  Thomas  Hospital  Reports,"  vol.  x,  new  series,  p.  241. 


224 


DISEASES   OF   THE   DLADDER. 


lick,*  and  i\ga\n  by  McAVhimiio. f  It  consists  (Fig.  T5)  of  a  metallic 
shield,  preferably  of  silver,  sufficiently  bulged  to  contain  the  protrud- 
ing vesical  wall  without  coming  into  contact  with  it.     The  edge  is 

rounded  oil  so  as  to  make  for  itself,  by 
l^ressure,  a  deep  groove  around  the  vesical 
tumor.  From  its  lower  part,  which  is 
slightly  bellied  downward,  extends  a  tube 
u})on  which  is  fitted  a  long,  flat  rubber 
bag,  to  be  worn  strajiped  to  the  tbigh, 
and  to  serve  as  a  reservoir  for  the  urine. 
The  bottom  of  the  bag  terminates  in  a 
metallic  screw,  which  can  be  removed  to 
allow  the  urine  to  drain  oil.  The  metallic 
shield  above  is  held  in  place  by  a  truss, 
which  serves  at  the  same  time  to  retain 
any  hernial  projections  in  the  groin. 
The  instrument  may  be  kept  clean  by 
the  use  of  a  weak  solution  of  permangan- 
ate of  potash.  "While  wearing  it,  the  pa- 
tient is  preserved  from  any  friction.  All 
the  urine  is  collected  as  it  flows,  and  a  con- 
siderable degree  of  comfort  is  obtained. 
Trendelenburg's  posterior  double  symphyseotomy  has  never  thus  far 
(188T)  succeeded  in  his  hands  in  securing  for  the  patient  continence 
of  urine.     I  think,  therefore,  it  is  not  to  be  recommended. 


Fig. 


HERNIA   OF   THE    BLADDER. 

Dislocation  of  the  bladder  in  the  form  of  hernia  may  be  congenital 
(rarely),  or  come  on  later  in  life,  especially  in  old  age,  from  exertion, 
retention,  or  violence.  Abdominal,  inguinal  (scrotal,  sometimes  on 
both  sides),  crural,  perineal,  ischiatic  hernise,  and  cystocele  through 
the  foramen  ovale  (Lentin),  have  been  noted.  In  women,  vaginal  and 
femoral  cystocele  are  most  common  ;  in  men,  scrotal — that  portion  of 
the  bladder  uncovered  by  the  peritonoeum  being  found  in  the  hernia. 
The  bladder  may  alone  constitute  the  hernia,  or  coexist  with  a  jiortion 
of  intestine,  perhaps  being  adherent  to  it.  Cystocele  has  been  opened 
by  mistake  in  operations  for  strangulated  hernia.  Pott  records  two 
cases.  Stagnation  of  urine,  with  inflammation  of  the  bladder  and 
formation  of  stone,  may  result  from  cystocele  ;  finally  the  hernia  may 
become  (rarely)  strangulated. 

The  diagnosis  is  usually  easy,  especially  with  a  catheter,  since 
the  tumor  increases  when  the  bladder  is  full,  and  may  be  emj)tied 

*  Plate  604,  "  Cyclopsodia  of  Anatomy  and  Physiology." 
f  "London  Medical  Gazette,"  1850,  vol.  xlv,  p.  300. 


HERNIA— nYPERTROniY.  225 

by  pressure,  such  pressure  causing  a  How  of  urine  tlirough  the  cath- 
eter. 

Hernia  of  the  bladder  was  first  observed  by  Sala  as  reported  by 
Bartholin.*  Verdicrf  in  1723  gave  the  subject  considerable  study. 
In  1874  Kronlein  published  a  case  of  strangulated  entero-cjstocele,  and 
Ch.  Leroux  discussed  the  subject  with  a  case,  and  Mr.  Larabrie,  refer- 
ring to  the  above,  reports  l  another  case  from  the  service  of  Mr. 
Duplay,  with  autopsy.  The  mechanism  of  hernia  of  the  bladder  is 
doubtless  that  laid  down  by  Nelaton  : 

1.  Distention  of  the  bladder  above  the  symphysis. 

2.  A  muscular  effort,  forcing  a  part  of  the  (thin)  bladder  into  the 
inguinal  canal. 

Treatmetif. — Replace  the  tumor,  if  possible,  and  retain  it  by  a  truss. 
If  it  be  irreducible,  a  suspensory  bandage  should  be  worn,  and  the 
tumor  emptied  by  pressure  during  urination.  If  it  become  strangu- 
lated, herniotomy  must  be  performed.  A  knowledge  of  the  possibility 
of  cystocele  is  the  best  safeguard  against  mistaking  it  for  ordinary 
hernia.  The  distinction  becomes  more  difficult  if  the  retained  portion 
of  the  bladder  is  much  thickened  by  chronic  inflammation,  or  contains 
stone.  Excision,  with  inversion  of  cut  edges  and  suture,  would  be  an 
entirely  justifiable  operation. 

PATENT   TTRACHUS. 

The  urachus  sometimes  remains  open  in  adult  life  and  urine  escapes 
through  it.  Stone  sometimes  forms  at  the  umbilicus  under  these 
circumstances.  I  have  cited  *  several  cases.  The  opening  at  the 
umbilicus  may  be  pared  and  sutured,  or  closed  by  cautery. 

HYPERTROPHY  OF  THE  BLADDER. 

Hypertrophy  of  the  bladder  as  a  spontaneous  affection  does  not 
exist.  It  is  exceedingly  common  in  connection  with  any  morbid  con- 
dition which  prevents  the  free  outflow  of  urine  (hypertrophy  of  the 
prostate,  stricture,  tumors),  with  stone,  or  in  connection  with  cystitis 
from  any  cause  (hernia  of  the  bladder,  etc.).  The  different  forms  of 
hypertrophy  (concentric,  eccentric,  with  sacculi)  are  described  as  part 
of  the  disease,  in  connection  with  the  morbid  conditions  occasioning 
them.  Civiale  speaks  of  a  partial  hypertrophy  of  the  bladder,  affect- 
ing chiefly  its  anterior  wall,  depending  upon  chronic  inflammation  or 
tubercular  infiltration — evidently  not  simple  hypertrophy. 

*  "M^moires  Anatomiques,"  1656. 

■j-  "Mem.  de  I'Acad  Koyale  de  Chirurgie,"  1753,  t.  ii,  p.  1. 
X  "Archives  Generales  de  Med.,"  March,  1881,  p.  342. 

*  "  International  Encyclopedia  of  Surgery,"  vol.  vi,  article  "  Urinary  Calculus." 

15 


326  DISEASES   OF   THE   BLADDER. 

ATROPHY    OF   THE   BLADDER. 

In  rare  cases  in  reduced,  soft-fibered,  debilitated  individuals  the 
bladder  may  be  found  weak  and  thin,  apparently  atvojihied  in  all 
its  coats,  and  liable  to  rupture.  Civiale  gives  the  caution  of  avoid- 
ing pressure  on  the  bladder  walls  during  catheterization  in  weak  sub- 
jects, for  fear  of  perforation.  Bonnet,  ilauf,  and  Hunter*  give  ex- 
amples of  sudden  rupture  of  the  bladder  in  young  persons  from  this 
cause.  Atonied  bladders,  and  those  whose  nervous  supjily  is  cut  off 
by  spinal  or  brain  disease,  undergo  more  or  less  fatty  atrophy. 

WOUNDS    OF    THE    BLADDER. 

"Wounds  of  the  bladder  are  not  common,  since  the  position  of  the 
organ  protects  it  from  ordinary  accidents,  inclosed  as  it  is,  when  in  a 
state  of  relaxation,  by  the  bony  pelvis.  Excepting  the  violence  done 
by  instruments  in  lithotomy,  possibly  in  lithotrity,  or  during  other 
operations,  the  bladder  is  but  little  liable  to  injury  except  during  dis- 
tention. It  may  be  perforated  by  a  fragment  of  bone  in  fracture  of 
the  pelvis.  Eising  above  the  symphysis  pubis  it  becomes  exposed  to 
incised,  punctured,  and  gunshot  wounds.  Wounds  of  the  bladder  are 
exceedingly  dangerous  to  life,  without  being  necessarily  fatal.  Bullets 
and  fragments  of  shell  have  entered  the  bladder  without  producing 
fatal  consequences, f  and  there  formed  nuclei  for  calculus — as  have 
also  portions  of  bone.  J 

Sometimes  the  bladder  is  very  tolerant  of  injury.  "Wittelshofer * 
reports  a  case  where  for  tliree  months  after  a  gunshot  injury  very 
little  inconvenience  was  experienced,  then,  after  straining  at  stool, 
which  probably  dislodged  the  foreign  body,  tenesmus  came  on  with 
bloody  urine,  and  the  patient  passed  a  piece  of  his  drawers  by  the 
urethra.  Next,  a  ball  weighing  five  grammes  was  removed  from  the 
bladder  by  operation,  and  finally  the  patient  passed  a  portion  of  his 
blue  military  trousers  through  the  urethra.  When  the  bladder  is  in- 
jured through  the  rectum,  the  prognosis  is  rather  good.  Among 
Bartel's  thirteen  cases  (collated),  ten  got  Avell. 

Treatment  of  injuries  of  the  bladder  is  that  of  symptoms  and  indi- 
cations—arresting haemorrhage,  and  making  a  free  outlet  for  urine,  as 
well  as  providing  an  escape  for  any  extravasated  fluid.     No  matter 

*  Quoted  by  Pitha. 

f  I  have  recorded  in  the  "Now  York  Journiil  of  Medicine,"  ^lay,  18G5,  the  case  of  an 
adult  whose  bladder  was  perforated  when  distended,  by  a  bullet,  during  the  New  York 
riots,  in  July,  1863  (the  gentleman  being  a  looker-on),  terminating  in  complete  recovery. 
— Van  Be  REN. 

X  Consult  P.  Maltrait,  "  Trauniatismes  de  la  Ve.ssie,"  Paris,  1881,  pp.  219. 

**  "  Wien.  med.  Wchnschrift."  and  "Int.  Journal  of  Med.  and  Surgery,"  Feb.  19, 
1881,  p.  187. 


RUPTURE.  227 

whore  the  perforation  may  be,  if  infiltration  is  going  on,  it  is  always 
better  to  set  the  bladder  at  rest  by  a  free  perineal  ineision,  and  digital 
exploration  of  the  entire  inner  surface  of  the  bladder.  It,  then,  there 
is  reason  to  belicye  that  the  peritoneal  cavity  has  been  opened,  lapa- 
rotomy is  the  proper  remedy,  the  peritoneal  cavity  being  cleaned  and 
the  bladder  wound  sewed  up.  The  perineal  opening  is  to  be  used  for 
tying  in  a  large  tube  for  drainage.  In  doubtful  cases,  suprapubic 
cystotomy  is  indicated  rather  than  the  perineal  opening. 

RUPTURE   OP   THE   BLADDER. 

A  bladder,  when  overdistended  by  urine,  may  become  ruptured 
by  external  violence,  and  this  especially  if  it  be  atrophied  or  thinned 
by  disease,  ulceration,  or  otherwise  ;  or  the  accident  may  occasionally 
happen,  if  the  bladder  be  previously  weakened  in  any  part,  by  the 
accumulation  of  urine  alone,  as  in  case  of  stricture.  Usually,  under 
such  circumstances,  the  immediate  cause  has  been  muscular  contrac- 
tion. The  most  frequent  cause  of  rupture  of  the  bladder,  as  com- 
monly met  with  in  practice,  is  a  fall,  the  bladder  being  distended. 
Imperforate  urethra  is  an  efficient  cause  in  the  foetus.  Among  trau- 
matisms, where  the  viscus  is  not  weakened  by  previous  ulceration, 
falls,  blows,  and  crushing  injuries,  with  or  without  fracture  of  the 
pelvis,  or  even  appreciable  injury  to  the  soft  parts,  may  be  mentioned. 
The  most  common  position  of  the  rupture  is  in  the  posterior  wall  of 
the  organ,  the  fissure  usually  including  the  peritoneal  coat.  Other 
portions  of  the  bladder  walls  occasionally  suffer. 

The  symptoms  are  sudden  occurrence  of  intense  pain  in  the  abdo- 
men, with  urgent  desire  to  pass  water,  while  attempts  to  urinate  are 
usually,  but  not  always,  ineffective.  Ordinarily  the  patient  is  unable 
to  walk  from  the  first.  Collapse  soon  follows.  Death  may  occur  in 
this  stage,  or  the  patient  reacts  and  passes  into  a  state  of  acute  peri- 
tonitis, or  suffers  from  symptoms  of  peritonitis  with  those  of  infiltra- 
tion. If  he  survive  the  acuteness  of  this  attack,  the  symptoms  merge 
into  those  of  local  peritonitis,  constant  and  often  ineffectual  desire  to 
urinate  being  still  a  prominent  symptom. 

The  catheter  passes  generally  without  difficulty,  and  clear  urine 
may  be  drawn,  or  urine  tinged  with  blood.  Whenever  a  diagnosis  of 
ruptured  bladder  can  be  made,  a  very  guarded  prognosis  must  be  given, 
as  a  vast  majority  of  the  cases  terminate  fatally.  Bartels*  makes 
intra-peritoneal  rupture  almost  necessarily  fatal,  but  Thorp's  case.f 
reported  as  intra-peritoneal,  got  well,  the  peritoneal  cavity,  it  is  stated, 

*  Lfwigenbeck's  "  Arcliiv,"  vol.  xxii,  Parts  III  and  IV.  Consult  also  Walter  Riving- 
ton,  "  Rupture  of  the  Urinary  Bladder"  (322  cases),  London,  ISSo-'Si,  pp.  160,  and  Chris- 
topher Heath's  interesting  paper,  "  Med.-Chir.  Trans.,"  vol.  Ixii. 

f  "  DubUn  Quarterly  Journal,"  vol.  xlvi,  p.  306. 


228  DISEASES   OF   THE   BLADDER. 

having  been  washed  out  through  a  catheter  passed  by  the  urethra.  It 
is  more  than  probable  that  this  was  an  extra-peritoneal  case.  Extra- 
peritoneal rupture  witbout  external  wound  is  fatal  in  seventy-four  per 
cent  of  all  .cases  according  to  Bartels.  AVeir  *  suggests,  as  a  means  of 
diagnosis,  that  a  measured  quantity  of  water  be  thrown  into  the 
bladder.     If  a  less  quantity  returns,  there  is  rui)ture. 

Treatment. — Whenever  rui)ture  of  the  bladder  can  be  diagnosti- 
cated, or  even  when  it  is  seriously  suspected,  modern  surgery  has 
demonstrated  that  the  only  safety  lies  in  opening  the  bladder.  There 
is  no  objection  to  making  a  perineal  opening  for  ex})loration,  and,  if 
the  rupture  is  extra-peritoneal,  this  alone  may  effect  a  cure,  as  Mason  f 
so  strongly  insisted,  and  as  a  number  of  cases  proved.  If,  after  such 
au  opening  is  made,  the  finger  detects  a  rent  in  the  bladder  walls 
threatening  the  peritona?um,  then  the  bladder  should  be  at  once  opened 
above  the  symphysis,  a  thorough  investigation  made,  the  peritonauim 
opened  if  necessary,  its  cavity  cleaned,  irrigated,  drained,  if  thought 
best,  and  the  bladder  wound  sewed  up.  A  tube  should  be  left  in  the 
periureum  for  drainage.  "When  intra-peritoncal  rupture  is  diagnosti- 
cated or  suspected,  laparotomy  is  imperative  as  the  patient's  only 
chance.  This  operation,  often  unfortunately  fatal  (Heath,  "Willett, 
W.  T.  Bull,  McGill,  Duncan,  Bonet),  has  yielded  brilliant  success — 
Walters,  J  MacOormac^  (two  cases),  and  T.  Holmes  ||  (one  case).  It 
is  undoubtedly  good  surgery  to  perform  suprapubic  cystotomy  in  all 
cases  of  ruptured  bladder,  and  to  treat  the  case  then  u^jon  its  merits. 
Among  the  interesting  successes  reported  may  be  mentioned  that  of 
Socin,"^  and  one  by  WaJsham.^ 

PERFORATING    ULCER    OF    THE    BLADDER. 

T.  H.  Bartleet,  of  Birmingham,  England,  reports  J  the  case  of  an 
engineer  who  stooped  rapidly  to  raise  an  iron  bar  from  the  ground, 
and  suddenly  felt  severe  pain  low  down  in  the  abdomen.  Eetention 
came  on,  relieved  by  catheter,  but  the  pain  increased.  There  were 
retching  and  constipation,  temperature  normal,  i)ulse  98.  Tlie  patient 
had  been  well  before  the  accident,  except  for  a  transient  retention  five 
years  previously.    In  eight  days  he  died.    On  autopsy  there  was  found 

*  "  On  a  Satisfactory  Method  of  Early  Diagnosing  an  Intra-pcritoneal  Rupture  of  the 
Bladder,"  by  Robert  F.  Weir,  M.  D.,  "Medical  Record,"  January  22,  1887. 

t  "  New  York  Medical  Journal,"  August,  18'72. 

X  "Philadelphia  Medical  and  Surgical  Reporter,"  February,  1802. 

*  Referred  to  in  "Lancet,"  December  11,  18SG,  p.  1118. 
II  "Lancet,"  July  23,  1887,  p.  153. 

^  "  Krrspndzbltt.  f.  scbwcizer  Acrzte,"  14,  1885,  and  "  Ceutralblatt  f.  Chir,"  45,  1885 
p.  791. 

0  "Lancet,"  March  12,  1887,  p.  539. 
\  "Lancet,"  February  5,  1870,  p.  210. 


FOREIGN   BODIES.  229 

an  oval,  cloan-cut  hole  one-half  by  three-eighths  inch  in  diameter 
exactly  in  the  middle  line  posteriorly  one  inch  above  the  apex.  This 
on  the  peritoneal  side.  In  the  bladder  this  hole  formed  the  bottom 
of  a  funnel-shai)ed  ulcer,  looking  like  a  gastric  ulcer,  which  obviously 
antedated  the  patient's  present  illness  (Bartleet  believed),  and  had 
gone  on  without  symptoms,  causing  adhesion  of  the  outside  of  the 
bladder  at  the  implicated  spot  with  the  ileum.  A  slight  separation  of 
the  adhesions  had  taken  place  when  the  man  felt  his  first  f)ain,  but 
this  had  been  enough  to  cause  escape  of  urine  and  peritonitis. 

FOREIGN    BODIES    IN    THE    BLADDER. 

Besides  the  foreign  bodies  *  which  find  theii;  way  into  the  bladder 
through  wounds,  or  come  down  the  ureters  (renal  calculi),  a  host  of 
substances  have  been  encountered  in  the  bladder,  introduced  through 
the  urethra.  All  unimaginable  articles,  such  as  pins,  beads,  stones, 
pieces  of  straw,  heads  of  rye,  heads  of  wheat,  squirrel's  tail,f  glass, 
tubing,  pipe-stems,  lead  and  slate  pencils,  portions  of  chalk,  wax,  etc., 
have  been  found  in  the  male  bladder,  introduced  there  through  the 
urethra  under  the  influence  of  morbid  erotic  fancies.  The  budding 
sexual  instinct  of  a  boy  yearns  for  satisfaction,  but  finds  none ;  is 
thoughtlessly  stimulated  by  the  youth  himself  by  impure  thoughts  or 
books,  often  kindled  by  those  who  are  older.  An  uneasy  feeling  of 
a  desire  to  do  something  leads  a  timid  boy  to  masturbation,  and  tempts 
him  to  play  all  sorts  of  pranks  with  his  sexual  apparatus.  In  this 
way,  substances,  of  every  conceivable  description  which  the  orifice  of 
the  urethra  will  admit,  are  introduced  into  the  canal  and  again  ex- 
tracted, until,  on  some  unlucky  occasion,  the  object  slips  beyond  the 
grasp  and  remains  fixed  in  the  deep  urethra,  or  the  bladder.  The 
patient's  shame  will  often  prevent  him  from  seeking  relief ;  a  small, 
smooth  foreign  body  in  a  healthy  bladder  may  create  no  disturbance 
at  first,  and  so  the  patient  goes  on,  supposing  that  everything  has 
arranged  itself,  until,  in  after  years,  perhaps  long  after  he  has  forgot- 
ten his  boyish  folly,  he  gets  bladder  symptoms,  is  cut  for  stone,  and 
the  latter  is  found  to  have  formed  upon  a  nucleus  introduced  from 
without. 

Not  infrequently,  however,  a  foreign  body  comes  legitimately,  as 
it  were,  into  the  bladder  ;  dermoid  cysts  containing  bones,  teeth,  and 
hair,  may  discharge  into  its  cavity.  The  broken  end  of  a  metallic  or, 
more  commonly,  a  gum-elastic  catheter  may  constitute  the  foreign 
body,  usually  in  cases  where  the  individual  is  obliged  to  have  frequent 
recourse  to  a  catheter  for  the  purpose  of  emptying  his  bladder.     A 

*  Consult  Poulet,  "Foreign  Bodies  in  Surgery,"  translation,  Wood,  N.  Y.,  1880,  p. 
145. 

f  "Am.  Journ.  Med.  Sci.,"  April,  18Y6,  p.  537. 


230  DISEASES  OF  THE  BLADDER. 

catheter  is  most  apt  to  break  at  tlie  eye.  The  okl-fashioned  gutta- 
percha bougie  is  particularly  dangerous,  on  account  of  its  liability  to 
become  brittle  when  old.  Such  bougies  should  not  be  used.  Again, 
substances  of  all  sorts,  bone,  seeds,  etc.,  may  enter  the  bladder  through 
ulceration  into  the  rectum,  while  splinters,  bullets,  and  bone  may  be 
lodged  there  during  injuries  of  the  bladder. 

Treaime?if. — If  the  foreign  body  be  a  portion  of  catheter  or  bougie, 
the  patient  will  usually  hasten  to  tell  his  troubles  and  demand  relief. 
If,  however,  it  be  some  other  foreign  body,  he  will  probably  seek  aid 
for  the  cystitis  it  may  have  occasioned,  but  will  steadfastly  deny  the 
knowledge  of  any  cause,  often  indeed  after  the  foreign  body  has  been 
detected,  or  even  extracted.  AVhen  the  natuz'c  of  the  substance  in  the 
bladder  has  been  learned,  an  attempt  should  be  made  to  extract  it,  to 
jirevent  it  from  becoming  a  nucleus  for  stone.  If  there  be  much  cys- 
titis present,  rest  in  bed,  with  demulcents  and  some  anodyne,  for  sev- 
eral days  before  the  operation.  Avould  be  advisable.  Anything  which 
will  go  into  the  urethra  would  come  out  of  it,  if  it  could  be  correctly 
seized,  with  its  points  turned  backward,  and  be  drawn  upon  in  a  cor- 
rect line  ;  consequently,  an  attemjit  should  be  made  to  reach  all  long 
bodies  (pencils),  and  all  small  bodies,  by  using  a  small  lithotrite,  or 
other  forceps  designed  for  this  si^ecial  purpose,  of  which  there  are  sev- 
eral varieties  kept  by  instrument-makers.  If  the  object  be  seized  in  a 
faulty  diameter,  it  may  be  released  and  caught  again.  This  rule  ap- 
plies to  portions  of  metallic  catheters  as  well.  It  is  exceedingly  diffi- 
cult to  catch  them  correctly  ;  soft  catheters,  however,  are  very  easy 
to  extract ;  they  become  doubled  up,  and  may  be  withdrawn,  however 
caught.  The  difficulty  in  seizing  a  portion  of  soft  catheter  is,  that 
it  can  not  be  felt  on  account  of  giving  no  click  or  grating  against  a 
metallic  forceps  ;  consequently,  in  the  search  for  such  a  foreign  body, 
the  blades  of  the  lithotrite  have  to  be  shut  occasionally  over  different 
parts  of  the  bladder  surface,  and  the  offending  body  is  pretty  sure  to 
be  found,  finalh%  between  its  jaws.  Care  must  be  exercised,  of  course, 
not  to  catch  a  fold  of  the  bladder. 

Two  substances  which  may  be  introduced  into  the  bladder  demand 
a  special  notice — wax  and  glass.  The  former  becomes  so  soft  at  the 
temperature  of  the  body  that  it  not  only  can  not  be  felt,  but,  if  seized, 
can  only  be  taken  away  piecemeal,  while  some  portion  is  pretty  sure 
to  remain  behind.  As  to  glass,  or  other  brittle  substance,  the  danger 
of  injuring  the  bladder  by  splintering  the  foi-eign  body  in  attempts  at 
extraction  with  forceps  renders  all  such  efforts,  as  a  rule,  unadvisable. 
Consequently,  for  all  foreign  bodies  of  wax  or  glass,  and  for  all  such 
as  can  not  be  extracted  after  patient  effort  with  the  lithotrite,  the 
median  operation  or  the  suprapubic  should  be  performed,  and  this  as 
early  as  possible,  before  the  foreign  body  has  had  time  to  become 
incrusted  with  urinary  salts.     If,  for  any  reason,  it  should  be  advisa- 


RETENTION   OF  URINE.  231 

ble  to  postpone  the  operation,  it  would  be  wise  to  wash  out  the  bladder 
daily  with  a  view  of  retarding  calculous  deposit  upon  the  nucleus.  Dr. 
Douglas,  of  Rondout,  N.  Y.,  in  cutting  a  patient  to  extract  a  piece 
of  glass,  fearing  that  pressure  with  his  forceps  might  splinter  it  in  the 
bladder  during  extraction,  devised  the  ingenious  expedient  of  covering 
the  blades  of  his  forceps  with  soft  molasses  candy,  knowing  that  if 
any  of  this  substance  was  left  in  the  bladder  it  would  melt  and  pass 
away.     The  device  was  fully  successful. 

RETENTION    OP    URINE. 

In  retention  the  bladder  fills  up,  and  the  urine  is  not  or  can  not  be 
passed.  It  must  be  clearly  separated  in  the  mind  from  suppression, 
where  no  urine  comes  down  from  the  kidneys.  This  distinction  can 
always  be  at  once  established  by  percussing  the  hypogastrium.  The 
causes  of  retention  are  varied  :  Voluntary  retention,  often  repeated  and 
long  kept  up,  may  result  in  positive  inability  to  empty  the  bladder ; 
all  varieties  of  urethral  obstruction — stricture,  enlarged  prostate,  in- 
flammation or  acute  congestion  of  the  prostate,  even  spasm  of  the  cut- 
off muscles — are  capable  of  producing  retention.  Finally,  true  vesical 
paralysis  will  give  rise  to  it,  unless  the  cut-off  and  sphincter  muscles 
are  paralyzed  at  the  same  time,  when  there  will  be  incontinence.  An- 
other cause  of  retention  is  found  in  the  blunted  sensibility  of  the  blad- 
der, which  exists  in  certain  high  febrile  conditions  (typhus,  small-pox), 
in  coma,  in  some  syphilitic  and  inflammatory  brain  diseases,  and  in 
shock  from  injuries,  and  in  all  conditions  of  spasm  of  the  deep  urethral 
muscles. 

Symptoms. — In  suppression  there  is  always  resonance  over  the 
pubes;  in  retention,  always  flatness.  The  bladder  may  be  often  seen 
and  felt,  filling  up  the  hypogastrium,  perhaps  reaching  the  navel. 
Pressure,  upon  it  usually  causes  a  desire  to  urinate.  Fluctuation  may 
be  made  out  between  a  finger  in  the  rectum  and  the  hand  upon  the 
hypogastric  tumor.  The  bladder  will  not  burst  from  retention  of 
urine,  unless  it  be  previously  ulcerated  or  subjected  to  mechanical  vio- 
lence when  full  (a  fall  or  blow)  ;  after  it  has  been  overdistended  for 
a  time,  a  certain  amount  of  dribbling  will  take  place  through  almost 
any  obstruction.  From  the  effect  of  violence,  or  if  the  urethra  be 
ulcerated  or  sensibly  weakened  behind  a  stricture,  extravasation  of 
urine  may  occur  through  the  urethral  walls. 

The  treatment  has  been  already  considered  in  relation  to  stricture 
and  prostatic  disease.  In  all  other  conditions — atony,  paralysis,  fever, 
etc. — a  soft  catheter  of  medium  size  should  be  passed  as  often  as  re- 
quired, and  the  bladder  should  be  washed  out  on  each  occasion  with 
a  hot  solution  of  borax  in  water.  Sometimes  a  large  silver  catheter 
of  soft  curve  passes  more  readily  than  a  soft  instrument.     In  cases  of 


232  DISEASES  OF  THE  BLADDER. 

retention  the  aspirator  will  always  afford  speed)'  relief,  Cazenave,  of 
Bordeaux,*  states  that  retention  may  be  relieved  by  introducing  a 
piece  of  ice  about  the  size  of  a  chestnut  into  the  rectum,  repeating 
the  same,  if  necessary,  every  two  hours.  This  expedient  is  useful, 
but  by  no  means  sure. 

INCONTINENCE    OF    URINE. 

Incontinence,  like  retention,  is  a  symptom,  and  not  a  disease.  In 
incontinence  a  portion  or  all  of  the  urine  dribbles  away,  or  is  passed 
involuntarily.  Besides  the  true,  there  are  two  very  common  forms  of 
false  incontinence — the  one  nocturnal,  occurring  in  children  ;  the  other 
in  adults  (stagnation,  with  overllow),  where,  after  retention  for  some 
time,  the  excess  of  urine  dribbles  away.  It  may  be  stated,  as  a  rule 
to  which  there  are  few  exceptions,  that  an  involuntary  flow  of  urine 
in  the  adult  indicates  retention  and  not  incontinence. 

NocTURXAL  IxcoxTiNEXCE  IN"  CiiiLDiiEX. — This  disagreeable 
affection  often  depends  upon  mismanagement :  children  not  being 
awakened  at  sufficiently  short  intervals  to  empty  their  bladders,  and 
acquiring  the  habit  of  passing  urine  without  being  waked  thereby.  In 
other  children,  again,  the  malady  is  sufficiently  marked  to  constitute 
a  disease.  In  these  cases  the  urine  escapes  during  the  unconsciousness 
of  sleep,  but  not  at  other  times.  Such  children  are  not  necessarily 
weak,  nervous,  or  choreic,  nor  do  they  belong  to  any  particular  con- 
stitution or  diathesis. 

Treatment  consists  in  paying  attention  to  the  child's  general  hygi- 
ene, awakening  it  to  pass  water  late  at  night  and  early  in  the  morning, 
using  moral  suasion,  and  avoiding  the  use  of  fluids  toward  evening. 
Besides  these  means,  absolute  benclit  may  be  expected  from  belladonna, 
commencing  at  a  small  dose,  perhaps  one  tenth  of  a  grain  of  the  ex- 
tract, if  the  child  is  very  young,  and  increasing  gradually  until  some 
of  the  poisonous  effects  of  the  drug  are  noticed.  Several  other  means 
maybe  mentioned  which  are  often  effective — blistering  the  i)erina3um, 
the  use  of  actual  cautery,  touching  it  several  times  about  the  anus. 
Recently  the  use  of  chloral  hydrate  has  been  advocated,  the  idea  being 
to  make  the  child  sleep  more  profoundly.  Another  means  which  has 
appeared  in  the  medical  journals,  and  has  been  employed,  it  is  said, 
with  success  in  breaking  up  the  habit,  is  sealing  the  prepuce  at  night 
with  a  drop  of  collodion.  Mechanical  appliances,  encircling  the  penis 
or  pressing  upon  the  perinaeum,  have  the  disadA^intage  of  tending  to 
beget  a  habit  of  handling  the  parts.  Cauterizing  the  deep  urethra 
sometimes  helps,  and  subcutaneous  injections  of  strychnine,  f 

*  "Journal  de  Medecine  et  de  Chirurgie,"  May,  1871. 

f  Kelp,  "  Deutsches  Archiv  f.  klin.  Med.,"  Cd.  xiv,  Heft  3,  4,  and  Uill,  "  Richmond  and 
Louisville  Medical  Journal,"  July,  1874. 


CHOREA.  233 

Incoktinence  in  Adults. — Stagnation  with  overflow  or  fuLso  in- 
continence has  been  already  considered.  True  incontinence  depends 
upon — 

1.  Unsymmctrical  development  of  the  prostate,  where,  after  the 
collection  of  a  little  urine,  the  rest  trickles  away,  there  being  no  dis- 
tention of  the  bladder. 

2.  Concentric  hypertrophy  of  the  bladder,  where  the  viscus  can 
not  distend,  and  all  urine  above  a  few  drachms  must  flow  at  once 
away. 

3.  Paralysis  of  the  "  cut-off  "  and  the  sphincter  muscles  of  the 
bladder  with  or  without  paralysis  of  the  detrusor  urinse. 

The  treatment  of  these  conditions  is  detailed  elsewhere.  It  is 
advisable  that  the  patient  should  wear  a  urinal. 

VESICAL   TENESMUS. 

Cramp  of  the  bladder  is  simply  an  uncontrollable  tenesmus  occur- 
ring in  the  course  of  several  inflammatory  diseases.  Where  there  is 
no  inflammatory  action  present,  it  may  be  classed  along  with  neu- 
ralgia of  the  vesical  neck,  in  which  condition  it  is  often  exceedingly 
severe. 

CHOREA    OF   THE   BLADDER. 

This  affection  is  rare,  and  seems  to  occur  only  in  children.  It 
usually  coincides  with  other  choreic  symptoms.  The  following  cases 
give  a  picture  of  the  disease  : 

,  aged  sis,  a  weakly,  lymphatic  boy,  of  rheumatic  antecedents,  growing  fast,  with 

a  moderate  appetite  and  large  head,  is  brought  by  his  mother,  with  the  complaint  that  he 
wets  his  pantaloons  while  at  play.  He  sometimes  soils  the  bed  at  night,  but  not  invari- 
ably. The  boy  knows  when  he  wets  his  clothes,  and  runs  to  tell  his  mother.  He  invari- 
ably declares  that  he  "can  not  help  it."  He  is  an  obedient,  gentle  little  fellow,  old 
enough  to  be  ashamed  of  himself,  and  seems  really  desirous  of  holding  his  water,  but,  as 
be  remarks,  he  "  can  not  do  it."  An  attempt  was  made  to  correct  the  habit  by  having 
the  boy  called  in  at  stated  intervals  from  his  play,  for  the  purpose  of  emptying  his  blad- 
der, but  the  involuntary,  spasmodic  escape  of  urine  still  occurred  occasionally  in  spite  of 
the  fact  that  the  bladder  was  not  allowed  to  fill  up.  This  boy  had  no  other  choreic 
symptoms,  except  in  the  muscles  of  his  right  eye.  Ordinarily,  his  eyes  were  straight, 
but,  when  tired,  or  excited,  or  angry,  or  frightened,  his  right  eye  would  be  drawn  out- 
ward— sometimes  outward  and  upward,  the  axis  of  the  other  eye  being  straight.  This 
strabismus  would  come  and  go  rapidly,  varying  according  to  the  voluntary  movements  of 
the  eye.  Moral  suasion  and  belladonna  were  equally  ineffective  in  relieving  the  vesical 
sjTnptoms  in  this  case,  but  tonic  and  general  hygienic  treatment  always  bettered  the 
patient,  until,  in  the  course  of  two  or  three  years,  his  bladder  returned  to  a  full  pos- 
session of  its  normal  functions,  and  his  strabismus  entirely  disappeared.  During  this 
period,  from  different  causes,  he  would  occasionally  get  run  down  in  general  health,  lose 
flesh  and  appetite,  and  then  his  involuntary  spasmodic  emissions  of  urine  day  and  night, 
and  his  tendency  to  intermitting  strabismus,  would  return.  The  urine  was  always 
normal. 


23i  DISEASES  OF  THE  BLADDER. 

In  this  case  there  was  evidently  a  spasmodic  contraction  of  the 
detrusor  iirinas  of  the  choreic  sort,  over  which  the  patient  had  no 
control.  There  was  no  stone  or  inflammatory  state  of  the  bladder, 
and  no  kidney  disease.  He  was  never  seen  in  the  act  of  making  water 
involuntarily,  so  that  it  is  impossible  to  state  whether  the  stream 
flowed  in  jets  or  continuously. 

,  aged  fourteen,  has  always  been  a  nervous  boy.     He  is  exceedingly  sensitive  in 

disposition,  very  bashful,  easily  excited,  or  brought  to  tears — general  iiealth  fairly  good. 
lie  has  been  under  treatment  for  sonic  time  past,  but  without  benefit.  He  is  troubled 
with  frequent  desire  to  urinate,  in  paroxysms — the  paroxysms  seeming  to  be  the  culmina- 
tion of  excessive  nervous  fidgetiness.  They  occur  especially  when  the  boy  is  annoyed 
about  anything,  and  are  almost  always  accompanied  by  a  sensation  of  chilliness.  He 
frequently  wets  the  bed  when  asleep,  and,  when  awake,  the  desire  to  urinate  comes  on  so 
suddenly  and  so  strongly  that  he  often  soils  his  clothing.  With  this  he  has  a  strong 
tendency  to  twitch  the  head  and  shoulders,  as  in  chorea.  lie  was  put  upon  iron,  quinine, 
and  arsenic,  with  general  hygienic  directions  about  food,  exercise,  and  fresh  air.  In  two 
months  he  reported  improvement.  His  treatment  was  continued,  and  he  was  ordered 
gnnnastic  exercise.     Nothing  further  was  heard  from  him. 

■ ,  aged  eight,  is  a  fat,  healtliy,  lymphatic  boy ;  one  of  a  large  family  of  children, 

of  whom  nearly  every  male  has  distinct  chorea,  either  generalized  or  afi'eeting  special 
muscles.  Some  of  the  older  children  have  outgrown  the  tendency.  The  patient  is 
troubled  occasionally  with  slight  general  choreic  twitehings,  when  from  any  cause  his 
appetite  is  low,  or  his  general  health  poor.  Under  such  circumstances  he  has  frequent 
paroxysms  of  intermitting,  uncontrollable  contraction  of  the  bladder,  forcing  him  to 
frequent  micturition  and  attempts  at  emptying  the  bladder  every  few  moments.  Some- 
times the  call  comes  so  suddenly  that  he  wets  his  clothing,  and  he  also  is  unfortunate  at 
night.  When  the  boy  is  enjoying  good  general  health,  neither  his  general  chorea  nor  his 
frequent  calls  to  urinate  disturb  him.  lie  improves  under  arsenic,  quinine,  or  any 
general  tonic  or  country  air. 

These  cases,  to  whicli  might  be  added  several  others,  make  out  a 
distinct  choreic  condition  for  the  bladder.  It  seems  to  be  a  rare  mal- 
ady, but  this  may  be  owing  to  the  fact  that  it  has  not  been  looked 
for.  It  occurs,  like  most  other  choreic  afPections,  in  early  life,  and  in 
conjunction  with  other  symptoms  of  local  or  general  chorea,  more  or 
less  strongly  marked. 

Treatment. — Correction  of  any  faulty  condition  of  life  by  improved 
hygiene  ;  iron,  arsenic,  quinine,  cod-liver  oil,  and  other  tonics  in  the 
way  of  drugs,  with  electricity,  constitute  the  treatment,  and  will 
probably  triumjih  over  any  case.     Local  measures  are  not  needed. 

HiEMATURIA, 

Haematuria  is  a  symptom  and  not  a  disease,  but  it  very  often  pre- 
sents itself  as  the  most  prominent  objective  characteristic  of  a  morbid 
condition.  Often  its  course  is  evident,  sometimes  so  obscure  that 
death  alone  reveals  it. 

Ha^maturia  is  the  passing  of  blood  with  the  urine.  The  blood  may 
be  free  or  in  clots.     There  may  be  so  little  that  it  is  only  discovered 


HEMATURIA.  235 

by  microscopic  examination,  by  which  moans  the  amber  biconcave 
disks  are  easily  detected  ;  there  may  be  enough  to  give  the  urine  a 
peculiar,  hazy,  smoky  hue,  which  is  very  characteristic  of  blood,  even 
when  there  is  no  pink  or  red  shade  in  the  specimen  ;  finally,  it  may 
be  so  abundant  as  to  make  the  urine  look  like  pure  blood,  or,  if  blood 
have  been  retained  for  a  considerable  time  within  the  bladder,  the 
urine  may  be  colored  almost  black  by  it. 

The  blood  usually  comes  from  the  urethra,  the  bladder,  or  the 
kidneys,  and  it  is  often  of  the  utmost  importance  to  decide  from  which 
of  these  three  sources  it  is  derived.  There  are  but  few  distinguishing 
marks.  If  the  bleeding  is  from  the  fore  part  of  the  urethra,  some  of 
it  will  reach  the  meatus  between  the  acts  of  micturition  ;  if  behind  a 
narrow  stricture,  or  posterior  to  the  membranous  urethra,  it  will  not. 
Blood  effused  into  the  urethra  clots  there,  and  assumes  the  shape  of  a 
leech,  or  of  a  tape  or  thread.  Such  clots  are  apt  to  come  out  with  the 
first  gush  of  urine,  although,  if  there  be  a  tight  stricture,  they  may 
not  be  able  to  squeeze  through  until  the  stream  is  running  at  full 
force,  and  consequently  would  not  appear  until  the  middle  or  near 
the  end  of  the  flow.  Blood  from  the  seminal  vesicles  will  be  clotted 
and  mingled  with  the  yellow  bodies  found  there,  and  with  spermatozoa. 
Blood  from  tlie  prostatic  sinus  is  pretty  sure  to  be  clotted,  perhaps  in 
strings  and  threads  mingled  among  flakes  of  pus-corpuscles.  When 
blood  comes  from  this  region,  the  spermatic  fluid  in  sexual  intercourse 
is  very  apt  to  be  bloody.  Blood  from  the  neck  of  the  bladder  may  or 
may  not  be  clotted.  .  Often  a  few  irregular  clots  will  come  first ;  then 
smoky  urine  will  flow,  and,  finally,  as  the  bladder  expels  its  last  drops, 
the  prostate  and  vesical  neck  being  squeezed,  a  little  highly-colored 
urine,  or  fluid  resembling  pure  blood,  will  be  voided. 

Blood  flowing  from  any  part  of  the  bladder,  and  sometimes  from 
the  prostatic  sinus  as  well,  if  it  flows  rapidly  into  an  empty  bladder, 
is  pretty  sure  to  clot  in  mass,  and  to  dissolve  afterward.  If,  however, 
it  flows  very  slowly,  or  into  a  bladder  partly  filled  with  urine,  it  may 
not  clot  at  all,  but  remain  freely  suspended  in  the  urine,  retaining  its 
natural  red  color ;  or,  after  a  few  hours,  become  brown  or  black  by 
the  deoxidizing  effect  of  the  urine,  the  red  oxyhgemogiobiu  becom- 
ing converted  into  brown  methgemogiobin.  Blood  may  clot  in  the 
pelvis  of  the  kidneys,  but  coming  down  from  the  kidneys  does  so 
usually  in  a  fluid  state,  either  as  red  or  black  blood  ;  fibrinous  clots 
may,  however,  pass  the  ureters  with  symptoms  of  kidney  colic. 
Blood  from  the  kidneys  has  no  special  physical  character  by  which  it 
can  be  distinguished  from  blood  coming  from  the  bladder,  except  in 
those  cases  where  blood-casts  of  the  uriniferous  tubules  are  found. 
These  are  pathognomonic.  The  quantity  of  blood  flowing  from  a 
cancerous  kidney  varies  very  greatly,  sometimes  disappearing  for 
weeks,  and  then  recurring  violently. 


236  DISEASES  OF  THE  BLADDER. 

Raver  *  says  tliat.  from  a  comparative  examination  extending  over 
a  length  of  time,  of  all  the  urine  passed  by  patients  with  calculous  pye- 
litis or  cancer  on  the  kidney,  he  noticed  several  times  (plKsieurs  foi)^) 
that  the  urine  voided  three  hours  after  eating  was  more  than  ordinarily 
loaded  with  blood. 

"Wlien  the  blood  comes  from  the  kidneys,  there  is  often  pain  or 
heaviness  of  the  lumbar  region  of  one  or  both  sides.  Blood  may  flow 
from  the  ureter  if  a  calculus  be  retained  there.  Raver  has  noted  sev- 
eral such  cases,  in  two  of  which  there  were  also  exuberant  granulations 
in  the  ureter,  which  bled. 

The  origin  of  blood  in  tlie  urine  may  in  some  cases  be  cleared  up 
by  a  clever  expedient  resorted  to  by  Thompson  for  the  ditferential 
diagnosis  of  pus  from  the  bladder  or  kidneys  in  obscure  cases.  A  soft 
catheter  is  gently  introduced  just  within  the  bladder  neck,  the  urine 
drawn  off,  and  the  cavity  washed  out  very  gently  with  tepid  water. 
If  the  water  can  not  be  made  to  flow  away  clean,  the  inference  is  that 
the  blood  comes  from  the  cavity  of  the  bladder.  If  it  will  flow  away 
clean,  then  the  catheter  is  corked  for  a  few  moments,  the  patient  being 
at  rest,  and  the  first  drachm  of  urine  which  collects  may  be  drawn  off 
and  examined.  The  bladder  is  now  again  washed  out,  and,  if  after 
a  single  washing  the  second  flow  of  injection  be  clear,  while  the  drachm 
of  urine  was  bloody,  the  inference  is  again  complete  that  the  blood 
comes  from  one  or  the  other  kidney.  Bloody  urine  is  always  albu- 
minous. 

The  causes  of  hmmaturia  are  very  numerous.  Among  the  most 
prominent  may  be  mentioned  all  traumatisms  of  any  character  of  the 
kidney,  ureter,  bladder,  or  urethra,  all  acute  inflammations  of  any  por- 
tion of  the  urinary  tract,  or  of  the  seminal  vesicles,  from  acute  ne- 
phritis to  gonorrhoea  and  urethral  chancre,  certain  forms  of  pyelitis  ; 
all  chronic  inflammations  of  these  same  regions,  especially  if  there  be 
ulceration  ;  overdoses  of  turpentine  when  the  blood  comes  fron[i  the 
kidney,  or  cantharides  when  it  comes  from  the  bladder ;  stricture 
(kidney,  bladder,  urethral,  or  stone),  strongulus  or  filaria  of  kidney, 
abscess,  cancer,  or  tumor  of  the  kidney  or  urinary  tracts ;  varicose 
condition  of  veins  near  the  bladder  ncck,t  villous  tumor  of  bladder; 
finally  may  be  mentioned  spontaneous,  so-called  essential,  haemor- 
rhage, sometimes  recurring  periodically  once  a  month,  like  feminine 
menstruation,  J  the  hemorrhagic  diathesis,  critical  hoemorrhage  in  cer- 
tain febrile  or  other  diseases  (typhoid,  variola).  These  discharges  may 
come  from  any  portion  of  the  urinary  mucous  membrane.  Paroxysmal 
hematuria,  due  to  malaria,  cold,  exposure,  etc.,  hemoglobinuria,  emo- 

*  "Maladies  des  Reins,"  Paris,  vol.  iii,  1841,  p.  333. 

t  Laiigier,  ''Gaz.  des  HOp.,"  No.  81,  1854,  and  Stein,  "New  York  Medical  Record," 
September  23,  1882,  p.  339. 
X  Rayer,  op.  cit.,  p.  333. 


NEURALGIA   OF  THE   NECK.  287 

tional  hsematuria,*  etc.,  arc  medical,  not  surgical,  forms  of  disease. 
Ilaematuria  is  endemic  in  some  localities,  South  America,  Isle  of 
France,  etc.  (due  to  the  parasite  Bilharzia  hmmaiohia). 

Treatment. — The  successful  treatment  of  hajmaturia  depends  upon 
discovering  a  cause  which  may  be  removed.  In  any  case,  however, 
alkaline  diluents  are  serviceable  by  rendering  the  urine  less  irritating. 

The  different  haemostatics  are  usually  of  no  service,  but  they  may 
be  tried,  and  occasionally  with  advantage.  Lead  and  opium  (aa  gr. 
j-ij),  three  or  four  times  daily  ;  ergot  (fluid  extract  tti  xx  to  3  j),  or 
subcutaneously  (gr.  v  of  ergotine)  ;  aromatic  sulphuric  acid,  3  C  -]' 
doses;  tincture  of  matico,  3  j- 3  C  doses;  alum,  sesquichloride,  sub- 
sulphate,  and  other  preparations  of  iron,  tannin,  gallic  acid,  creo- 
sote, Oak-Orchard  mineral  water,  Eockbridge  Alum  mineral  spring ; 
last,  but  not  least,  turpentine. 

Rest  on  the  back  is  often  necessary  above  all  things,  and  in  this 
position  ice  may  be  applied  with  advantage  to  the  hypogastrium,  peri- 
naeum,  and  in  the  rectum.  Lallemand  employed  nitrate  of  silver  in 
the  bladder,  and  iron  and  alum  solutions  have  been  injected  with  more 
or  less  benefit.  It  is  necessary  to  repeat  here  one  caution  already  given 
in  another  section  :  If  the  bladder  becomes  filled  up  with  a  large  clot 
of  blood,  let  it  alone  ;  no  harm  will  come  of  it.  It  will  dissolve  and 
come  away  ;  any  attempt  to  pump  it  out  through  a  catheter,  or  break 
it  up,  or  dissolve  it,  if  successful,  will  only  allow  the  blood  to  re-col- 
lect, and  is  fraught  with  the  danger  (for  the  patient)  of  exciting  in- 
flammation by  violence.  The  best  treatment  is  opium,  to  control 
desire  to  urinate,  rest,  and  diluents.  HoUman  f  injected  gr.  xvi  of 
pepsin  in  one  case,  and  in  a  few  hours  a  dark,  viscid  fluid  escaped 
readily  through  the  catheter.  Pm'oxide  of  hydrogen  is  said  to  dis- 
solve clot. 


NEURALGIA    OF    THE    VESICAL    NECK. 

This  most  common  affection  of  the  bladder  has  received  its  clearest 
exposition  from  Civiale,  who  has  devoted  nearly  a  hundred  pages  to  it 
in  his  '•'  Traite  des  Maladies  des  Organes  genito-urinaires,"  Paris,  1858. 
Phillips  X  treats  of  it  as  "contracture  du  col  de  la  vessie,"  a  title  first 
given  the  disease  by  Caudmont,  another  Parisian  surgeon,  whose  views 
are  given  in  English  by  Dr.  Slade,*  of  Boston.  Gross  |  gives  a  case 
under  the  title  of  neuralgia  of  the  bladder,  using  the  term  neuralgia 
in  its  English  sense,  to  which  the  idea  of  pain  is  attached.    The  French 

*  I  have  a  case ;  Basham  and  Rayer  have  reported  cases, 
f  "Nederland  Weekblatt,"  IS,  1SS2,  p.  272. 

X  "Traite  des  Maladies  des  Yoies  urinaires,"  Paris,  1860. 

*  "  Boston  Medical  and  Surgical  Journal,"  July,  1855. 
II  "  Diseases  of  the  Urinary  Organs." 


238  DISEASES  OF   TUE   BLADDER. 

expression  ''ncvralgie"  docs  not  necessarily  include  the  idea  of  pain, 
but  signifies  simply  a  nervous  disorder — functional,  not  organic.  The 
anatomical  scat  of  the  disease  is  the  prostatic  sinus  around  the  seminal 
ducts  as  well  as,  and  indeed  more  strictly  than,  the  neck  of  the  blad- 
der. The  nervous  element  of  hyperesthesia  of  the  deep  urethra  and 
vesical  neck  bears  a  large  share  in  producing  the  symptoms  of  nearly 
all  bladder  diseases.  Neuralgia  in  its  pure  form  has  very  clear  out- 
lines, but  the  part  it  plays  when  engrafted  ujion  other  bladder  and 
urethral  diseases  throws  confusion  into  their  diagnosis  and  clironicity 
into  their  type. 

The  causes  of  neuralgia  of  the  vesical  neck  are  numerous,  but  none 
holds  the  same  prominence  as  does  the  perversion  of  the  sexual  in- 
stinct and  appetite,  its  overstimulation  by  excess,  or,  more  often,  its 
imperfect  satisfaction — in  short,  irregular  or  ungratified  sexual  desire. 
The  action  of  these  causes  is  to  congest  and  keep  in  a  more  or  less 
constant  condition  of  irritation  the  prostatic  sinus  in  the  neighborhood 
of  the  seminal  ducts.  This  congestion  extends  readily  in  both  direc- 
tions, involving  the  cnt-ofE  muscles  in  front  and  creeping  backward 
into  the  neck  of  the  bladder  through  the  inner  orifice  of  the  urethra. 
Rarely,  if  ever,  does  this  affection  occur  in  its  typical  form  (simijle 
irritability  of  the  bladder,  without  inflammatory  lesion) — rarely  does 
it  so  occur  where  the  sexual  element  is  not  at  fault.  It  attacks  men 
young  and  old,  married  and  single,  but  the  great  majority  of  cases 
will  be  found  in  young  bachelors,  recently-widowed  gentlemen,  and 
old  bachelors.  Where  the  youth  of  the  patient  or  the  married  state 
would  seem  to  throw  a  sexual  cause  out  of  possibility,  almost  invari- 
ably there  will  be  found,  by  close  questioning,  on  the  one  hand  mas- 
turbation or  the  encouragement  of  budding  erotic  fancies  by  impure 
thoughts  and  associations  ;  on  the  other,  excess,  infidelity,  or  imper- 
fect and  unsatisfactory  sexual  relations.  So  close  is  the  connection 
between  an  unnatural  sexual  condition  and  an  unhealthy  state  of  Lhe 
neck  of  the  bladder,  that  it  needs  but  little  practical  observation  of 
cases  to  convince  one  that  these  influences  alone  are  to  blame  for  the 
origin  of  some  and  for  the  long  continuance  of  many  other  morbid 
vesical  conditions. 

Second  to  this  sexual  cause  in  producing  neuralgia  of  the  vesical 
neck  comes  the  arthritic  or  gouty  diathesis,  that  general  blood  con- 
dition attended  by  acidity  and  concentration  of  the  secretions,  local 
congestions  so  often  of  the  tegumentary  structures,  with  neuralgic 
and  irritable  habit.  Finally  comes  a  long  line  of  causes  including 
everything  capable  of  inflicting  a  structural  change  upon  the  tissues 
of  the  neck  of  the  bladder  or  in  its  neighborhood  (stricture,  abscess, 
large  j)rostate,  inflammations,  stone,  worms,  inflamed  hnsmorrhoids, 
fissure  of  rectum,  etc.);  and  though  these  in  themselves  are  not 
necessarily  complicated  by  neuralgia  of  the  vesical  neck,  yet  they  keep 


NEURALGIA   OF   THE   NECK.  gOQ 

np  congestion  there  and  often  arc  thus  complicated,  where  the  urine 
is  irritating,  the  constitution  arthritic,  or  especially  the  sexual  appe- 
tite at  the  same  time  perverted  or  ungratified.  The  nervous  hypo- 
chondria, with  despondency,  the  excited  and  suspicious  tendencies  so 
marked  and  remarkable  in  nearly  all  men  at  any  time  of  life  in  con- 
nection with  functional  or  organic  trouble  in  the  genito-urinary  tracts, 
are  only  explicable  by  recognizing  that  Nature  has  implanted  in  man 
the  sexual  want  which  controls  many  actions  of  his  life,  impels  him 
to  continue  his  species,  and  cries  out  in  distress  whenever  it  is  trifled 
with,  ungratified,  or  overstimulated,  or  whenever  its  existence  seems 
to  be  menaced.  A  man  will  feel  more  depressed  at  seeing  a  little 
excess  of  phosphate  in  his  urine  which  he  thinks,  in  spite  of  all  proof 
to  the  contrary,  indicates  a  local  "weakness,"  than  he  will  at  loss  of 
memory  or  mental  incapacity  which  he  can  recognize  himself  and  be 
fully  conscious  of.  There  are  few  men  who  would  not  rather  lose  a 
leg  or  an  eye  than  a  testicle  ;  while  functional  or  organic  disease  of 
the  bladder,  testicles,  or  penis,  causes  more  mental  inquietude  and 
distress  to  its  possessor  than  does  a  cavity  in  a  lung.  Why  should  this 
be,  except  that  Nature  has  endowed  man  with  an  instinct  of  terror  at 
the  idea  of  losing  his  sexual  capacity,  and  has  established  a  law  for  the 
regular  and  judicious  performance  of  the  sexual  act,  which  he  must 
obey  or  else  suffer  in  some  way  the  penalty  ?  This  suffering  may  not  be 
evinced  by  symptoms  in  the  organs  of  generation  themselves,  and  prob- 
ably will  not  be  unless  through  excitement  of  these  organs  by  abuse  or 
irregular  use,  or  unless,  through  their  stimulation  by  erotic  fancies, 
the  patient  attract  the  morbid  nervous  tendency  to  a  local  explosion. 
A  man  perfectly  pure  in  thought  and  deed  would  not  suffer  from 
vesical  neuralgia,  unless,  of  course,  some  physical  lesion  of  the  parts 
should  first  occur  to  excite  local  congestion.  Old  maids  and  priests 
suffer  from  sexual  distress  as  much  as  young  and  old  bachelors  and 
widowers,  but  they  very  rarely  give  any  local  signs  of  trouble.  Their 
symptoms  may  be  scattered  over  all  the  organs,  and  may  impair  any 
or  all  of  the  functions. 

Symptoms. — Pure  neuralgia  of  the  vesical  neck  is  synonymous  with 
the  condition  vaguely  known  as  irritability  of  the  bladder.  This 
affection  is  totally  denied  by  some  authors,  who  affirm  that  a  lesion 
exists  in  all  cases,  and  that  it  is  simply  a  confession  of  ignorance  to 
talk  of  pure  irritability.  The  charge  can  not  be  justly  made.  A 
cause  for  irritability  can  always  be  discovered,  where  there  is  no  ap- 
preciable lesion,  by  studying  the  sexual  wants  and  relations  of  the 
individual.  It  is  expedient,  however,  to  drop  the  term  irritability  of 
the  bladder  as  meaning  a  disease,  and  to  retain  it  in  the  signification 
only  in  which  it  has  been  adopted  in  this  country — as  indicative  of 
that  symptom,  common  to  nearly  all  bladder  affections,  frequent 
desire  to  urinate,  where  the  cause  lies  in  the  bladder — hence  not  ia 


240  DISEASES  OF  THE  BLADDER. 

diabetes  or  hysteria.  This  at  ouce  reduces  irritability  from  a  disease 
to  a  symptom,  aud  the  term  may  be  used  in  ordinary  description  as 
synonyniDUS  with  "' frequent  desire  to  urinate.''  Irritability  maybe 
found  in  connection  with  inilammatory  alTections  caused  directly  by 
the  inllammation  or  in  the  same  affections  ke])t  up  and  aggravated  by 
neuralgia  of  the  vesical  neck. 

The  symptoms  of  a  pure  case  are  as  follows  :  Frequent  desire  to 
urinate,  the  attack  coming  on  sometimes  suddenly,  sometimes  grad- 
ually, without  appreciable  cause,  or  i)erhaps  commencing  in  an  inilam- 
matory condition  of  the  parts  (gonorrhcea),  but  not  subsiding  with  the 
latter.  This  desire  to  empty  the  bladder  may  or  may  not  be  attended 
by  a  slight  burning  pain  in  the  act.  In  severe  cases  there  is  powerful 
tenesmus  (cramp).  The  relief  after  urination  is  usually  not  perfect, 
and  the  desire  soon  returns.  There  is  often  a  certain  slowness  in  the 
act,  the  bladder  contracting  without  force,  and  the  stream  being  small, 
or,  on  the  other  hand,  the  bladder  may  contract  spasmodically  Avhen 
the  call  conies,  throwing  out  the  urine  with  great  force.  Again,  there 
may  be  spasmodic  contraction  of  the  cut-off  muscles  leading  to  inabil- 
ity to  urinate,  or  hesitation  in  the  act. 

There  are  some  prominent  peculiarities  about  these  calls  to  urinate. 
They  rarely  disturb  the  patient  at  night.  Once  asleep,  he  rests  quietly, 
but,  if  from  anxiety  or  other  causes  he  is  restless  and  w^akcful,  he  is 
obliged  to  empty  his  bladder  frequently,  by  night  as  well  as  by  day. 
When  under  the  stimulation  of  liquor,  the  urine  can  sometimes  be  held 
for  a  number  of  hours.  When  pleasantly  occupied,  or  deeply  inter- 
ested in  anything,  as  at  the  theatre,  in  agreeable  company,  or  engaged 
at  some  earnest  w'orkj  the  bladder  is  often  but  little  if  at  all  trouble- 
some. On  rainy,  damp,  or  cold  days,  the  calls  to  urinate  are  more 
frequent,  perhaps  once  an  hour.  The  same  occurs  during  idleness, 
and  especially  during  mental  worry  or  disquietude.  The  spirits  are 
usually  depressed,  the  patient  anxious,  perhaps  hypochondriacal.  The 
urine  is  usually  clear,  rarely  shows  any  purulent  deposit  (unless  the 
affection  has  lasted  for  mouths  or  years),  but  often  contains  an  excess 
of  amorphous  phosphates.  This  deposit  sometimes  alternates  from 
week  to  week  with  a  deposit  of  urates.  Sometimes  both  ingredients 
exist  in  excess.  Crystals  of  oxalate  of  lime  are  not  uncommonly  jires- 
ent.  There  is  no  soreness  over  the  pubes,  though  pressure  there  will 
sometimes  call  forth  a  desire  to  urinate.  In  the  rectum  there  is  often 
a  slight  sensation  of  heat  and  uneasiness.  There  is  frequently  a  dull, 
dragging,  uncomfortable  feeling  in  the  perina3um — but  pressure  there 
is  not  painful.  Erections  may  be  frequent  or  absent — the  latter  to 
such  an  extent  that  the  patient  may  believe  himself  impotent.  There 
may  be  abnormal  feelings  of  heat  and  tenderness  about  the  scrotum 
and  testes.  Added  to  these,  there  may  be  all  sorts  of  functional  dis- 
turbances of  the  bowels,  often  constipation,  with  feelings  of  lassitude. 


NEURALGIA   OF   THE   NECK.  241 

and  general  weakness.  Sjiasmodic  stricture  of  the  urethra  may  oome 
on  as  an  accom])animent  of  this  condition,  while  great  irritability  of 
the  cut-off  muscles  exists  as  a  rule.  Nocturnal  emissions  are  not  infre- 
quent. 

On  exploring  the  urethra  with  a  full-sized,  blunt,  steel  sound  in 
these  cases,  it  is  customary  to  find  the  whole  canal  sensitive  and  irrita- 
ble. The  muscular  fibers  contract  about  the  instrument,  and  oppose 
its  progress.  At  the  membranous  urethra,  the  cut-off  muscles  con- 
tract spasmodically,  often  sufficiently  to  bar  the  progress  of  the  sound 
entirely,  and  give  the  idea  of  organic  stricture.  As  the  instrument 
advances,  the  cut-off  muscles  may  be  felt  to  quiver  in  slight  partial 
contractions,  while  the  patient  complains  greatly  of  pain.  When  the 
beak  of  the  sound  enters  the  prostatic  sinus,  the  patient  is  very  apt  to 
feel  faint.  He  may  indeed  go  into  syncope,  or  have  an  attack  of  nau- 
sea ;  or,  perhaps,  a  sexual  orgasm  may  be  induced,  in  which  case  the 
prostate  and  cut-off  muscles  contract  violently  upon  the  sound,  caus- 
ing the  patient  considerable  joain.  As  the  sound  jiasses  the  neck  of 
the  bladder,  either  the  natural  feeling  of  a  desire  to  urinate  will  not 
be  perceived  or  (usually)  the  sensation  will  be  highly  exaggerated  and 
painful.  Sometimes  spasm  of  the  bladder  will  be  induced,  and  the 
instrument  will  be  forced  out,  or  a  jet  of  urine  may  gush  out  along 
the  urethra  outside  of  the  instrument.  On  withdrawing  the  sound,  a 
little  blood  will  often  be  found  upon  the  beak,  but  the  patient  as  a 
rule  feels  relieved,  and  will  often  experience  for  hours  thereafter  an 
ease  and  local  comfort  such  as  he  has  been  a  stranger  to  for  months, 
perhai3S  for  years ;  his  interval  of  urination  being  decidedly  length- 
ened, although  the  smarting  at  the  next  urinary  act  will  be  greater 
than  before.  The  above  general  outline  of  symptoms  will  include 
most  cases  of  pure  neuralgia  of  the  vesical  neck,  where  there  is  no 
lesion,  and  has  been  no  serious  antecedent  disease. 

As  for  the  symptoms  of  a  nervous  element  complicating  the  differ- 
ent structural  diseases  of  the  genito-urinary  tract,  a  detail  is  impossi- 
ble. Suffice  it  to  say  the  symptoms  drag  out,  the  disease  tends  to  run 
a  chronic  course,  attended  by  morbid  excitability  of  the  prostatic  ure- 
thra, and  an  irritability  of  the  neck  of  the  bladder  which  is  out  of 
proportion  to  the  lesions  existing.  This  irritability  is  not  constant ; 
it  is  worse  one  day,  better  another,  and  subject  to  variations  which  no 
physical  conditions  can  account  for.  Where  such  prolongation  of  the 
symptoms  and  an  excitable  state  exist  in  connection  with  organic  dis- 
ease of  the  parts — but  out  of  proportion  to  them — a  profound  study 
of  the  case  will  often  bring  out  some  sexual  distress  which  is  finding 
this  means  of  expression. 

Pure  and  simple  neuralgia,  if  continued  long  enough,  may  finally 
lead  to  a  mild  cystitis  around  the  neck  of  the  bladder — especially  if 
the  patient  give  way  to  his  frequent  calls  to  urinate,  and  strain  to  void 

16 


242  DISEASES   OF  THE   BLADDER. 

tlie  last  drops  of  urine,  thereby  nicchanically  bruising  the  congested 
vesical  neck  and  exciting  it  to  inflame,  just  as  too  frequent  stools  pro- 
duce an  analogous  condition  of  tlie  lower  end  of  the  rectum.  After 
such  inflammation  has  been  kindled,  and  true  cystitis  exists,  the  neu- 
ralgic element  persists  with  it  as  a  rule.  The  history  of  the  advent  of 
the  attack,  the  excessive  sensitiveness  and  irritability  of  the  cut-off 
muscles,  and  a  diagnosis  by  exclusion,  will  rarely  fail  to  detect  neural- 
gia of  the  vesical  neck  as  the  acting  cause  of  cystitis  where  it  is  so. 
Such  cystitis  may  be  prolonged  for  years  and  finally  end  in  death,  as 
in  Gross's  case,  believed  by  that  eminent  surgeon  to  be  of  malarial 
origin. 

These  cases  require  more  careful  study  than  pcrluqis  any  other 
affection  of  the  urinary  organs,  and  are  in  many  instances  mistaken 
for  and  treated  as  organic  disease. 

Diaf/nosi,<t. — The  diagnosis  of  neuralgia  of  the  vesical  neck  is  easy 
when  considering  the  sensibility  of  the  nrethra  as  above  narrated,  the 
insensibility  of  the  bladder  walls  when  touched  with  the  i)oint  of  the 
sound,  and  the  great  fact  that  the  urine  of  pure  neuralgia  contains  no 
sensible  deposit  of  pus,  while  that  of  cystitis  always  does.  Where  the 
two  conditions  coexist,  the  points  noted  above  will  help  to  clear  up  the 
diagnosis,  and  establish  the  neuralgic  element,  if  it  exist. 

The  ireatmefit  is  simple,  and,  if  it  can  be  carried  out,  usually  brill- 
iantly effective.  An  alkali,  if  necessary,  general  hygiene,  and  atten- 
tion to  the  sexual  element — by  marriage,  if  possible,  by  continence,  if 
there  is  excess  ;  by  purity  of  thought  and  deed  in  any  case — will  place 
the  patient  in  a  curable  condition.  A  mineral  acid,  with  possibly  a 
little  strychnine — if  the  urine  be  neutral  or  phosphatic  ;  an  avoidance 
of  alcoholic  beverages,  and  a  cessation  of  the  use  of  tobacco,  may  be 
required,  with,  possibly,  change  of  residence,  occupation,  or  habits 
that  keep  up  an  irritable  condition  of  mind.  With  these  general  means 
nothing  is  so  potent  locally,  in  a  pure  case,  as  the  use  of  a  moderately 
sized  conical  steel  sound,  well  warmed  and  oiled,  and  introduced  with 
the  utmost  gentleness.*  The  time  for  reintroduction  will  depend  upon 
the  duration  of  the  effect  of  a  single  use  of  the  instrument.  If  there 
is  prostatitis  or  cystitis,  the  instrument  will  aggravate  the  local  condi- 
tion ;  if  neuralgia,  its  gentle  use  will  always  be  followed  by  comfort, 
and  the  relief  will  last  a  variable  time.  In  old  subjects  it  is  sometimes 
necessary  at  first  to  reintroduce  the  instrument  every  day  ;  in  younger 
people  every  second,  third,  or  fourth  day,  until  a  cure  is  effected.  The 
action  of  the  instrument  seems  to  be  to  blunt  the  morbid  sensibility  of 
the  i^arts  by  pressure,  to  improve  the  circulation  by  temporarily  squeez- 
ing out  the  blood,  and  by  putting  the  irritated  muscles  lightly  upon 
the  stretch.     No  internal  medication  can  be  relied  upon  in  this  com- 

*  In  some  cases  deep  urethral  instillations  of  a  few  drops  of  a  mild  solution  of  the 
nitrate  of  silver  give  even  better  results  than  the  sound. 


CYSTITIS.  243 

plaint.  If  the  symptoms  rise  high  uiid  approach  those  of  cystitis, 
a  small  amount  of  anodyne  by  the  rectum  may  be  serviceable  for  a 
time. 

When  a  neuralgic  condition  of  the  vesical  neck  complicates  and 
prolongs  or  aggravates  an  existing  organic  disease,  even  here  the  gentle 
use  of  the  steel  sound  is  often  followed  by  marked  benefit,  although  it 
may  temporarily  seem  to  aggravate  some  of  the  symptoms.  In  these 
cases  the  sexual  element  must  be  attended  to  in  some  way,  while  the 
best  effects  are  often  produced  by  a  cessation  from  business  cares,  trav- 
eling a  few  weeks  in  the  country,  or  a  course  of  baths  at  some  water- 
ing-place— the  character  of  the  water  being  a  matter  of  small  impor- 
tance. 


CHAPTER  XIII. 

DISEASES  OF  THE  BLADDER. 


Acute  Cystitis.— Gonorrhoeal  Cystitis.— Diagnostic  Table  of  Cystitis  of  tlie  Necli  and  Prostatitis.— 
Pathological  Lesions  in  Cystitis.— Treatment.— Chronic  Catarrh  of  the  Bladder.— Atony  of  the 
Bladder.— Paralysis,  Heterologous  Deposits,  and  Tumors,  in  the  Bladder- Walls. 

IiSTFLAMMATTOisr  of  the  bladder,  according  to  the  anatomical  portion 
of  its  walls  involved,  is  known  as — 

Cystitis  m.ucosa — catarrh  of  the  bladder. 

Interstitial  cystitis. 

Pericystitis  ;  epicystitis. 

These  varieties,  however,  do  not  demand  detailed  and  separate  de- 
scriptions, since  they  follow  one  upon  the  other  as  grades  of  intensity 
of  the  same  morbid  process.  Thus,  it  may  be  said  that  no  form  of 
bladder  inflammation  can  exist  alone,  except  that  affecting  the  mucous 
coat.  Epicystitis  may  do  so,  but  only  as  a  peritonitis  involving  the 
outside  covering  of  the  viscus.  Vastly  the  greater  proportion  of  mor- 
bid causes  acting  to  produce  bladder  inflammation  in  the  male  exert 
their  influence  directly  upon  its  mucous  membrane,  and  consequently 
the  modality  assumed  by  the  inflammation  is  that  of  catarrh  of  the 
free  (mucous)  surface.  If,  now,  from  long  continuance  or  great 
severity  of  the  catarrhal  inflammation  (formation  of  ulcers  and  slough- 
ing), the  morbid  action  should  extend  deeper  and  involve  the  connect- 
ive tissue  of  the  walls  of  the  bladder,  the  cystitis  at  once  becomes 
interstitial,  possibly  eventuating  in  abscess.  During  all  this  time  the 
catarrhal  cystitis  keeps  up,  the  interstitial  variety  being  only  an  ex- 
tension of  the  latter.  Abscess  may  form  in  the  bladder-walls,  and 
break  externally,  without  communication  with  its  cavity. 

Pericystitis  is  an  inflammatory  condition  of  the  connective  tissue 


244  DISEASES   OF  THE   BLADDER. 

around  and  outside  of  the  bladder.  Tiiis  may  result  from  an  exten- 
sion of  interstitial  cystitis,  or  may,  and  usually  does,  depend  upon 
infiltration  of  urine,  or  external  violence.  The  diagnosis  jireseuts  no 
difficulties.  .  The  alfection  occurs  after  great  meelianical  violence  to 
or  in  the  region  of  the  bladder,  from  infiltration  or  as  a  result  of  long- 
continued  interstitial  cystitis.  Jn  pericystitis  a  point  of  suppuration 
will  be  found  sooner  or  later  outside  of  the  bladder. 

During  interstitial  cystitis  the  bladder  gradually  contracts  do^n, 
undergoing  concentric  hypertrophy  ;  its  walls  thicken  enormously, 
possibly  reaching  the  thickness  of  an  inch.  Abscess  may  form  in 
them  ;  its  cavity  becomes  nearly  obliterated,  perhaps  down  to  half  an 
ounce ;  incontinence  ensues ;  the  mass,  like  a  Jiard,  smooth,  wooden 
ball,  may  be  felt  in  the  hypogastrium,  or  from  the  rectum,  of  a  size 
varying  with  the  duration  of  the  disease.  It  may  be  as  large  as  a 
man's  tist.  It  is  not  necessarily  A-ery  sensitive  to  pressure,  and  is 
smooth  and  of  even  hardness  on  its  surface.  This  condition  of  blad- 
der disease  is  not  curable.  Its  walls  can  not  be  redilated.  Palliation 
is  the  treatment,  mainly  by  anodynes. 

Inflammation  of  the  bladder  is  not  found  as  an  idiopathic  essential 
disease  ;  that  is,  it  does  not  occur  except  through  the  intervention  of 
some  cause  acting  locally.  Tlius,  the  effect  of  cold,  so  active  in  pro- 
ducing catarrhal  inflammation  of  certain  mucous  membranes  (con- 
junctival, Sclmeidcrian,  bronchial,  intestinal),  is  powerless  to  excite 
inflammation  in  a  healthy  bladder,  however  active  it  may  be  in  kin- 
dling an  existing  congestion  or  chronic  inflammation  into  an  acute 
state.  The  exception  to  this  non-existence  of  idiopathic  C3'stitis,  found 
with  certain  acute  diseases,  and  with  paralysis  from  sjiinal  or  brain 
lesions,  is  explained  by  recognizing  the  local  effect  of  overdistention, 
or  of  acid  or  retained  (decomposing)  urine.  Gonorrhoeal  cystitis  is  a 
complication,  not  an  essential  disease.  In  tubercle  and  cancer,  as  well 
as  in  diphtheria,  there  must  be  a  local  deposit  in  the  bladder-walls 
before  cystitis  comes  on.  The  nearest  approach  to  an  essential  cystitis, 
if  it  may  be  so  called,  is  found  in  that  form  produced  by  an  overdose 
of  cantharides.  This  substance  has  the  power  of  directly  congesting 
the  vessels  of  the  neck  of  the  bladder  and  prostate — and  such  a  cystitis 
could  hardly  be  called  idiopathic. 

From  the  foregoing  it  is  evident  that  acute  cystitis  does  not  occur 
spoil taneously,  and  is  an  exceedingly  rare  affection,  except  as  an  ex- 
acerbation of  already-existing  chronic  disease,  or  following  traumatic 
causes,  mechanical  or  chemical  (irritating  urine).  Chronic  cystitis, 
on  the  other  hand,  is  very  common,  so  much  so  that  there  are  few 
diseases  of  the  urinary  passages  of  which  it  does  not  form  a  part. 
Chronic  cystitis,  moreover  (unlike  many  other  chronic  inflammations), 
rarely  commences  as  an  acute  disease,  but  is  chronic  from  the  first, 
becoming  afterward  acute,  from  time  to  time,  by  the  action  of  pro- 


ACUTE   CYSTITIS.  245 

yoking  causes.  Chronic  cystitis,  therefore,  would  naturally  demand 
consideration  first,  but,  for  convenience  of  description,  the  artificial 
order  is  adopted. 

ACUTE   CYSTITIS. 

The  causes  of  acute  cystitis  are  fivefold  : 

1.  Traumatic,  mechanical,  or  chemical. 

2.  Extension  of  inflammation  (gonorrho3a,  inflammation  of  prostate, 
neighboring  abscess). 

3.  Exacerbation  of  existing  chronic  inflammation. 

4.  Specific  action  of  drugs  (cantharides). 

5.  JSTeurotic. 

1.  Traumatic  Causes. — Any  thing  capable  of  doing  mechanical 
violence  to  the  bladder-wall,  especially  to  its  mucous  membrane  near 
the  neck,  may  occasion  acute  cystitis.  The  rough  use  of  instruments, 
as  in  crushing  stone  ;  wounds  of  the  bladder-walls  by  mechanical  ob- 
jects, or  fracture  of  pelvis  ;  the  presence  of  stone  ;  pressure  of  a  neigh- 
boring tumor.  In  the  last  two  cases  some  chronic  cystitis  always  pre- 
cedes its  acute  manifestation  :  mechanical  distention  from  retention 
caused  by  stricture,  acute  febrile  disease,  coma,  or  jDaralysis,  acting  in 
conjunction  with  altered  urine  ;  chemical  violence,  irritating  injec- 
tions, very  acid  and  concentrated  urine — all  these  act  as  traumatic 
causes. 

2.  Extension  of  Inflammation. — As  in  gonorrhceal  cystitis,  pros- 
tatic inflammation,  neighboring  abscess.  Here,  also,  chronic  inflam- 
mation, jjerhaps  of  short  duration,  appears  first. 

3.  Exacerbation  of  existing  chronic  inflammation  from  the  effect 
of  cold,  acid  urine,  rough  treatment  by  instruments,  spontaneous  in- 
crease of  symptoms  depending  on  neuralgia  of  the  vesical  neck,  a 
diphtheritic  patch  of  membrane,  etc. 

4.  Cantharides,  terehinthinates,  etc.,  acting  specifically. 

5.  Neurotic,  following  neuralgia  of  the  vesical  neck. 
Symptoms. — The  symptoms  of  acate  cystitis  are  the  same,  whether 

the  affection  be  primary  or  ingrafted  upon  an  already  altered  state  of 
the  local  circulation.  The  calls  to  urinate  are  frequent  and  impera- 
tive, by  night  and  day.  The  feeling  of  relief  after  micturition  is 
absent.  The  act  is  accompanied  by  smarting  pain,  with  tenesmus. 
Pain  of  a  heavy  burning  character  is  felt  in  the  perinseum,  and  above 
the  pubes,  radiating  thence,  perhaps,  to  the  end  of  the  penis,  to  the 
loins  and  baclv,  or  down  the  thighs.  The  urine  contains  pus  in  greater 
or  less  quantities,  at  first  evenly  distributed  through  the  fluid,  then 
voided  as  stringy  mucus  (whence  the  name  catarrh).  Portions  of 
bladder-wall  may  slough  from  the  intensity  of  the  inflammation,  in 
which  case  the  urine  contains  shreds  of  sloughy  tissue,  gases,  etc.,  and 
has  a  gangrenous  odor.     The  reaction  of  the  urine,  at  first  acid  or 


246  DISEASES  OF  THE   BLADDER. 

neutral,  bccoinos  alkaline.  Triple  and  amorphous  i)liosphates  are 
found  deposited  in  excess.  Blood  appears  in  the  urine  in  greater  or 
less  quantities,  perhaps  pure  liquid,  or  in  clots.  There  is  rarely  a 
chill,  but  fcyer  may  run  high,  with  all  its  accompanying  symptoms, 
dry  tongue,  great  restlessness,  jactitation — hiccough,  if  gangrene  be 
present.  Mental  inquietude,  apju-chension,  anxiety  and  distress,  are 
prominent  features  of  acute  cystitis,  and  are  never  entirely  absent. 

Acute  cystitis,  from  whatever  cause,  presents  the  above  general 
group  of  symptoms.  A  few  words  of  special  detail  are  necessary  re- 
garding the  gonorrhceal  form. 

GoNORKiicEAL  CYSTITIS. — This  aflfcction  comes  on  during  the  ex- 
istence of  gonorrha?a,  or  urethritis,  or  even  of  a  gleet — if  the  gleet 
depend  upon  the  stricture — l>y  direct  continuation  of  the  inflammation 
backward  upon  the  mucous  membrane.  The  inflammation  is  confined 
to  the  region  of  the  neck,  and  does  not  attack  the  body  of  the  bladder. 
It  never  appears  until  after  the  first  week  of  a  gonorrhcea,  rarely  till 
after  the  third  week,  when  the  urethral  inflammation  has  reached  the 
lower  portions  of  the  canal.  It  is  more  frequently  seen  in  practice  as 
a  result  of  simple  extension  of  inflammation  later  in  the  course  of  the 
disease.  Often,  however,  a  second  or  provoking  cause  has  been  in 
action,  and  without  its  assistance  the  complication  of  gonorrhceal  cys- 
titis might  have  been  escaped.  These  provoking  causes  are  anything 
which  will  irritate  the  urethra  ;  the  use  of  alcoholic  beverages,  sexual 
intercourse,  abortive  treatment  of  gonorrhoea,  catheterism,  jolting, 
violent  or  even  sometimes  moderate  exercise,  where  the  urine  is  acid, 
and  the  patient  nervous  and  excitable.  Any  of  these  causes  may  light 
up  a  mild  cystitis  of  the  neck  in  any  patient  with  urethritis. 

Symptoms. — The  symptoms  of  gonorrheal  cystitis  vary  from  a 
hardly  appreciable  irritability — with  congestion — up  to  the  very  high- 
est grade  these  symptoms  (of  irritability)  can  assume,  Avith  a  tenes- 
mus so  constant  as  to  amount  to  actual  incontinence,  the  patient 
voiding  a  few  drops  of  blood  or  milky  fluid  every  few  minutes.  The 
tenesmus  is  particularly  painful,  although  the  mere  passage  of  urine 
is  often  attended  by  great  pain.  A  noteworthy  featjire  of  gonorrhroal 
cystitis  is  the  absence  of  general  phenomena.  Fever  is  sometimes 
inappreciable,  and  rarely  runs  high.  Anxiet}'^,  malaise,  and  nervous 
distress,  are,  however,  disproportionately  prominent.  Constipation  is 
habitual.  The  urethral  discharge  becomes  greatly  lessened,  or  even 
disappears  on  the  advent  of  the  bladder  symptoms  ;  as  the  latter  dis- 
appear, however,  the  former  returns.  Gonorrhceal  cystitis  varies  in 
duration  from  a  few  days,  in  abortive  cases,  up  to  many  weeks,  and 
sometimes  leaves  permanent  trouble  behind  in  the  pelvis  of  the  kidney 
or  in  the  seminal  vesicle. 

Acute  prostatitis  can  always  be  differentiated  from  cystitis  of  the 
neck,  gonorrhceal  or  other,  by  the  rectal  touch,  which  detects  a  hot. 


GONORRHEAL   CYSTITIS— TREATMENT.  24:7 

throbbing,  swollen  prostate  in  the  one  cuse,  nothing  of  the  sort  in  the 
other. 

That  form  of  cystitis  produced  by  cantharides  is  really  a  strangury. 
Great  congestion  of  the  vessels  of  the  bladder's  neck  exists  with  con- 
stant tenesmus.  It  is  rare  to  meet  cases  of  this  kind  at  the  joreseiit 
day.  Older  authors  refer  to  them  produced  by  the  administration  of 
"love-potions"  by  ''  witches."  Constant  priapismus  accompanies  the 
tenesmus,  and  the  result  in  the  worsb  cases  may  be  sloughing  of  the 
penis,  and  death.     There  may  or  may  not  be  erotic  excitement. 

The  pathological  cJianges  produced  by  acute  cystitis  upon  the  blad- 
der-wall and  its  membrane  are,  briefly,  capillary  injection  of  the 
mucous  surface,  changing  the  pale  salmon-tint  into  a  brilliant  crim- 
son, the  color  being  perhaps  uniform,  perhaps  in  patches,  with  a  more 
or  less  punctate  appearance.  There  may  be  ecchymotic  spots,  purple- 
colored  patches  mixed  with  red.  The  mucous  membrane  is  softened 
and  swollen.  These  changes  usually  commence  at  the  neck  and  often 
remain  limited  to  this  locality,  but  may  extend  over  the  whole  in- 
ternal surface  of  the  bladder.  The  glandular  follicles  near  the  neck 
become  involved,  enlarged,  and  surrounded  by  a  red  areola.  In  cer- 
tain high  grades  of  inflammation  the  membrane  may  be  ulcerated, 
or  patches  of  false  membrane  encountered.  This  croupous  character 
has  been  especially  observed  in  the  cystitis  caused  by  cantharides. 
True  patches  of  diphtheritic  exudation  have  been  observed  secondarily 
in  the  bladder.  There  may  be  sloughs  of  the  mucous  membrane,  or 
of  more  or  less  of  the  thickness  of  bladder-walls,  or  interstitial  thick- 
ening, with  or  without  abscess  (interstitial  cystitis),  or  abscess  around 
the  bladder,  with  more  or  less  peritonitis.  Purulent  venous  thrombosis 
has  been  found,* 

With  these  evidences  of  acute  cystitis  may  be  mingled  the  marks 
of  older  chronic  inflammation  ;  such  as  a  thickened,  condensed,  tough 
structure  of  the  mucous  membrane  and  bladder-walls,  colored  in 
purple  and  red,  or  of  a  bluish-gray,  slate-colored  tint ;  trabeculization, 
sacculation,  ulceration,  perhaps  pus  in  or  around  the  bladder- walls  ; 
possible  gangrenous  patches  ;  the  mucous  membrane  may  be  incrusted 
with  urinary  salts,  etc. 

Treatment. — The  general  treatment  of  acute  cystitis  from  any 
cause — gonorrhoea  as  well — is  the  same.  It  rests  firmly,  as  already 
indicated  for  prostatitis  (p.  208),  upon  the  tripod  of  rest  in  bed,  with 
elevation  of  pelvis  ;  alkaline  diluents  ;  enough  anodyne  to  relieve  pain 
and  tenesmus.  To  these  may  be  added  local  application  of  heat.  If 
there  be  any  removable  cause  (presence  of  a  catheter  tied  into  the 
bladder),  it  should  be  taken  away.  If  the  cause  be  stone  or  a  foreign 
body,  no  attempt  should  be  made  to  remove  it  until  the  intensity  of 
the  inflammation  has  been  quieted  by  the  means  above  alluded  to.  If 
*  Walsham,  London  Path.  Soc,  April  29,  1SY9.     "Lancet,"  May  10,  1879,  p.  665. 


OJ-S  DISEASES   OF   TUE  BLADDER. 

cautliaridcs,  turpentine,  or  ciibcbs  is  boiu^t;  taken  by  tlie  patient,  it 
should  be  discontinued  during  the  acute  stage  of  the  affection,  to  be 
resumed  in  the  subacute  stage.  Copaiba  sometimes  works  wonderfully 
well  in  quieting  acute  symptoms,  but  it  can  not  be  relied  upon.  As- 
paragus should  not  be  eaten  by  a  initient  with  acute  cystitis  ;  common 
salt,  strong  coffee,  and  lemon-juice  should  be  also  avoided.  There  is 
no  occasion  for  any  local  or  general  abstraction  of  blood,  but  the  medi- 
cines and  measures  detailed  at  pages  201,  202  should  be  studiously 
enforced.  If  the  cystitis  be  a  strangury  from  cantharidcs,  plenty  of 
opium — or  camphor  in  emulsion — and  a  very  free  use  of  diluents,  must 
be  relied  upon.  In  all  cases  repeated  use  of  a  full  hot  bath  has  a 
soothing  effect — or  of  the  hip-bath.  The  rectum  should  be  kept  free 
by  copious  warm  enemata,  and  opiates  should  be  given  by  the  rectum 
and  not  the  mouth.  Absolute  rest,  with  the  hips  raised,  and  alkaline 
diluents,  alone  suthce  in  mild  cases.  If  abscess  form  in  or  around  the 
walls  of  the  bladder,  an  opening  should  be  made  externally  through 
the  hypogastrium,  rectum,  or  perin^eum,  at  the  earliest  possible  mo- 
ment, to  prevent  perforation  of  the  mucous  membrane,  and  the  possi- 
ble danger  of  infiltration. 

The  most  effective  special  treatment  for  gonorrhceal  cystitis  is  the 
instillation  into  the  membranous  urethra  in  the  manner  already  indi- 
cated (p.  TT),  with  a  deep  urethral  syringe,  of  a  few  drops  of  a  solution 
of  the  nitrate  of  silver,  at  a  strength  varying  from  one  to  forty-eight 
grains  to  the  ounce,  every  few  days.  The  effect  is  often  magical. 
Ten  grains  to  the  ounce  is  usually  strong  enough.* 

The  key  to  the  treatment  of  pe?'ici/stitis  is  to  open  abscess  wher- 
ever it  tends  to  point,  making  the  opening  carefully  and  very  early. 

CHRONIC  CATARRH  OF  TEE  BLADDER. 

Of  all  the  affections  to  which  tlie  bladder  is  subject,  chronic  ca- 
tarrh holds  the  first  rank  in  regard  to  frequency.  It  never  occurs  as 
an  idiopathic  affection,  but  is  invariably  a  secondary  result  arising 
from  other  morbid  conditions  of  the  urinary  passages.  Once  started, 
it  does  not  tend  to  get  well  spontaneously,  but  to  become  slowly  and 
steadily  worse.  Fortunately,  its  causes  are  well  known,  and  most  of 
them  easy  of  demonstration.  Many  of  these  can  be  removed,  and 
with  them  the  chronic  inflammation  which  they  keep  up.  Some 
cases  arc  incurable  on  account  of  permanent  structural  alterations  in 
the  bladder-walls,  or  where  the  cause  can  not  be  reached.  All,  how- 
ever, may  be  benefited  by  careful  and  judicious  management,  and 
there  are  few  abnormal  conditions  of  the  body  whose  amelioration  is 
attended  by  more  satisfaction  on  the  part  of  the  surgeon,  or  more 
gratitude  on  that  of  the  sufferer. 

*  Consult  a  paper  by  me,  "Xcw  York  Medical  Record,"  May  28,  ISSY. 


cniioxic  CYSTITIS.  249 

Causes. — Almost  all  the  organic  diseases  of  the  urinary  passages 
are  attended,  during  some  part  of  their  course,  by  more  or  less  chronic 
catarrh  of  the  bladder ;  so  much  so,  that  a  study  of  the  altered  con- 
dition of  the  bladder  forms  a  part  of  the  picture  of  the  disease,  and 
has  to  be  considered  with  it.  Hence,  most  of  the  varieties  of  chronic 
catarrh  are  disposed  of  elsewhere  under  the  heads  of  other  diseases. 
For  their  study  the  reader  is  referred  to  the  proper  section  (stone, 
stricture,  prostatic  disease).  All  causes  of  chronic  vesical  catarrh  may 
be  arranged  under  three  main  heads  : 

1.  Mechanical,  including  obstructive  prostatic  and  urethral  dis- 
eases, stone,  morbid  growths  in  the  bladder  or  rectum,  or  around  tlie 
bladder,  hernia  of  the  bladder,  exstrophy,  retention  of  the  urine,  sud- 
den taking  off  of  the  pressure  of  accumulated  urine  from  an  habitually 
overdistended  bladder,  neuralgia  of  the  vesical  neck. 

2.  Cliemicctl.  Very  acid  urine  (rarely),  decomposing  alkaline  urine, 
from  the  liberated  ammonia  frequently  ;  atony,  paresis  of  the  muscu- 
lar coats  and  true  paralysis,  inasmuch  as  they  invariably  tend  to  i)ro- 
duce  decomposition  of  the  urine  by  stagnation. 

3.  Reflex,  from  kidney  disease,  stone,  pyelitis,  urethral  anterior 
constriction,  tight  meatus,  inflammation  in  seminal  vesicles,  etc. 

Many,  in  fact  most  cases  of  chronic  cystitis,  result  from  the  com- 
bined action  of  both  mechanical  and  chemical  causes.  In  obstructive 
disease  from  stricture  or  large  prostate,  added  to  the  mechanical 
stretching,  the  chemical  action  of  the  decomposing  urine  is  always  at 
work.  The  same  may  be  said  of  retention.  Eetention  alone,  in  a 
healthy  bladder,  will  not  necessarily  cause  cystitis,  although  it  may  do 
so  from  the  mere  mechanical  violence  done  by  stretching.  The  con- 
stant slight  violence  due  to  voluntary  retention  pushed  beyond  a  nor- 
mal limit,  and  often  repeated,  will  eventuate  in  cystitis.  The  same 
holds  good  of  the  sudden  but  extreme  retention  occurring  in  coma, 
shock,  the  acute  fevers,  etc.,  if  it  be  not  relieved.  In  these  conditions 
of  unconsciousness  or  delirium,  the  well-informed  physician  is  always 
on  the  lookout  for  the  state  of  the  bladder,  frecpiently  palpating  and 
percussing  the  hypogastrium  to  see  that  all  goes  well.  It  is  very 
gratifying,  in  these  cases,  to  observe  the  instantaneous  i-elief  which 
may  be  afforded  by  inserting  a  soft  catheter,  and  emptying  the  over- 
distended  bladder.  Even  if  overflovy  has  come  on,  the  regular  use  of 
the  catheter,  preventing  prolonged  overdistention,  may  avert  the  im- 
pending cystitis  and  atony.  Yet,  in  practice,  not  a  few  cases  of 
cystitis  will  be  found  to  take  their  origin  in  retention,  during  fever 
or  unconsciousness,  not  promptly  recognized.  On  the  other  hand 
very  acid,  or  even  slightly  decomposing  urine,  would  not  excite  in- 
flammation in  a  bladder  unless  its  circulation  and  tone  were  already 
impaired,  as  by  atony,  paralysis,  etc.  Finally,  one  other  causative 
factor  of  cystitis  deserves  a  word ;  namely,  extension  of  chronic  in- 


250  DISEASES   OF   THE   BLADDER. 

flammatiou  backward  from  a  v.rcthra  or  prostate  already  chronicalh' 
inUamod. 

Of  the  two  sets  of  causes  tlie  mcchanic((l  act  far  more  frequently, 
the  chemical  usualh'  coming  in  to  assist  them  in  their  work. 

Clironic  cystitis  from  mechanical  causes  is  disposed  of  elsewhere 
(stricture,  hypertrophied  prostate,  inflammatory,  tuhercular,  cancerous 
or  other  prostatic  disease,  cystitis  from  stone). 

Trauinatic  violence  in  the  bladder,  as  elsewhere,  is  attended  by 
inflammation.  Morbid  growths  in  or  around  and  pressing  upon  the 
bladder,  cause  chronic  cystitis  by  obstruction  to  free  escape  of  urine,  by 
calling  an  extra  amount  of  blood  to  the  part,  and  by  the  mechanical 
bruising  which  the  bladder-walls  sustain  against  them.  Again,  the 
tumors  themselves  may  inflame,  or  their  discharges  cause  decomposition 
of  the  urine,  thus  exciting  chronic  catarrh.  In  hernia  of  the  bladder 
there  is  mechanical  obstruction  to  circulation,  with  distention,  and  de- 
composing urine.  In  exstrophy  there  are  friction  with  clothing,  ex- 
posure to  the  air,  and  mechanical  obstruction  to  circulation.  A  blad- 
der gradually  accustomed  to  habitual  overdistention  may  give  its 
owner  no  ajipreciable  annoyance,  but  the  mechanical  stretching  here 
has  modified  and  weakened  the  circulation  of  the  part,  and  produced 
atony,  and  when  all  the  tension  is  suddenly  let  up,  and  the  bladder 
allowed  to  collapse,  the  blood  is  very  apt  to  rush  suddenly  into  and 
overdistend  the  weakened  vessels,  and  result  in  a  condition  of  in- 
flammation, the  iy])Q  of  which,  however,  at  first,  is  more  often  acute 
than  chronic — and  grave  at  all  times. 

In  long-continued  neuralgia  of  the  vesical  neck,  the  mechanical 
active  cause  is  the  constant  and  continued  bruising  of  the  bladder- 
neck,  by  often  repeated,  perhaps  violent  and  spasmodic  contractions 
in  micturition.  Added  to  this  sufficient  cause  .  is  a  second  one, 
namelv,  an  extension  of  congestion  backward  from  the  engorged  mem- 
brane of  the  jirostatic  sinus. 

TJie  chemical  causes  conducing  to  cystitis  have  been  alluded  to  in 
connection  with  overdistention  of  the  organ  (stricture,  enlarged  pros- 
tate). Very  acid  urine  rarely  causes  cystitis,  being  more  apt  to  pro- 
duce urethral  inflammation  ;  acting,  however,  upon  an  already  con- 
gested bladder,  it  always  tends  to  heighten  the  grade  of  the  congestion 
or  inflammatory  process.  Decomposing  urine  will  sooner  or  later 
light  up  cystitis,  on  account  of  the  irritating  properties  of  the  am- 
monia wdiich  it  evolves,  and  in  atony  or  paralysis  there  would  be  no 
cystitis  without  the  action  of  this  cause.  The  first  edition  of  this 
treatise  contains  a  case  clearly  demonstrating  this  fact  (Case  XXXI). 
A  fertile  source  of  chronic  cystitis  is  chronic  inflammatory  or  irritative 
kidney  disease,  notably  pyelitis — by  reflex  irritation.  This  is  often 
overlooked  even  by  the  most  experienced  observers,  the  urethra  is  cut, 
the  bladder  injected,  the  perinaeum  incised,  when  it  finally  turns  out 


CHRONIC   CYSTITIS.  251 

that- the  trouble  was  not  cystitis  at  all,  but  a  stone  in  the  kidney,  pye- 
litis, or  pyelo-nepliritis,  or  nephrosis. 

Symptoms  of  Chronic  Cyditin. — The  symptoms  of  chronic  cys- 
titis resemble  those  of  the  acute  form,  in  a  degree  proportionate  to  the 
grade  of  the  inflammatory  process.  There  may  be  only  a  little  in- 
creased frequency  of  urination,  with  slight  cloudiness  of  the  fluid,  as 
seen  in  the  history  of  enlarged  prostate  ;  or  the  calls  may  be  very  fre- 
quent, and.  the  pains  excessive,  varied,  and  constant,  as  in  the  acute 
disease.  In  fact,  chronic  cystitis  is  liable  at  any  time  to  be  lighted  up 
into  an  acute  state  by  the  continued,  action  of  its  own  cause,  or  by  the 
supervention  of  others  (effect  of  cold,  violent  exercise,  abuse  of  alco- 
hol, acid  urine).  The  urine  of  chronic  cystitis  always  contains  pus, 
either  freely  suspended  through  the  fluid,  or,  more  often,  in  gouts 
and  clots  of  stringy  muco-pus,  more  or  less  mingled  with  crystals  of 
triple  phosphates  and  with  blood.  Pus  which  is  passed  in  the  liquid 
state  may  become  converted  into  "stringy  mucus,"  while  standing,  by 
the  alkaline  decomposition  of  the  urine,  or  the  process  may  be  imi- 
tated artificially  in  a  test-tube^  by  adding  ammonia  or  liquor  potassse 
to  urine  containing  free  pus.  The  latter  immediately  becomes  trans- 
lucent, coherent,  and  is  indeed  the  substance  commonly  called 
"stringy  mucus." 

Diphtheritic  casts  of  the  entire  bladder  have  been  passed  by  females 
during  life,  and  found  in  the  male  after  death.  I  have  heard  of  one 
such  being  passed  by  a  male,  but  I  did  not  see  it.  Fibrinous  shreds 
passed  by  the  male  are  not  very  uncommon. 

Treatment. — Chronic  cystitis  being  an  affection  always  entertained 
by  some  other  morbid  process,  its  treatment  consists  in  the  removal  of 
the  cause.  Some  of  these  causes  are  removable,  others  are  not.  In  the 
latter  case  the  treatment  is  palliative,  and  addressed  to  symj)toms. 
After  the  removal  of  the  cause  the  chronic  cystitis  will  get  well  in  early 
life,  or  at  any  age,  unless  there  has  been  organic,  permanent  change 
induced  in  the  bladder-walls  (hypertrophy,  sacculation).  For  these  lat- 
ter cases,  or  where  the  cause  can  not  be  removed,  the  i^alliative  treat- 
ment is  as  follows  :  For  acute  exacerbations,  the  same  as  for  acute 
cystitis,  based  on  the  tripod  attitude,  alkali,  anodyne  ;  for  the  forma- 
tion of  abscess  in  or  around  the  bladder- walls,  besides  the  above,  an 
early  and  carefully  made  opening  ;  for  the  continuous  chronic  state  the 
treatment  consists  in  keeping  the  urine,  as  it  comes  from  the  kidneys, 
slightly  alkaline,  washing  out  the  cavity  of  the  bladder  with  warm 
water,  then  with  medicated  injections  (p.  197),  if  an  instrument  can  be 
introduced  ;  and  in  the  use  of  a  small  amount  of  anodyne  in  suppository 
at  night,  when  the  pain  is  great.  The  balsam  of  coj^aiba,  cubebs,  tur- 
pentine, and  the  infusions  of  buchu,  triticum  repens,  uva-ursi,  flaxseed, 
etc.,  may  also  be  sometimes  of  use.  The  value  of  counter-irritation 
over  the  hypogastrium  must  always  be  kept  in  view.     These  means- 


252  DISEASES   OF   THE   BLADDER. 

aided  by  as  much  rest  as  is  consistent  witli  health,  change  of  air,  and 
hygienic  details  in  regard  to  food,  etc.,  will  elTect  all  the  relief  that  can 
be  atforded.  Where  there  is  an  element  of  neuralgia  of  the  vesical 
neck  in  the  case,  it  must  be  suitably  treated  (p.  '212).  The  peculiar- 
ity of  chronic  cystitis,  depending,  as  it  always  does,  upon  some  other 
morbid  condition,  renders  its  special  description  unsatisfactory,  and 
begets  a  necessity  for  constant  reference  to  the  other  allections  which 
underlie  it. 

Some  of  the  modern  suggestions,  which  may  be  used  with  advantage 
in  some  cases  in  a  general  way  to  reduce  chronic  cystitis,  are,  fluid  ex- 
tract of  corn  silk,  milk  diet,  nai)htlialine,  benzoic  acid  and  the  ben- 
zoates,  salicylic  acid.  An  admirable  bladder  irrigation  is,  gr.  ss.  to 
grs.  iij  nitrate  of  silver  to  the  pint  of  water. 

Cydotomy  for  Chronic  Cydith. — This  operation  has  grown  in 
favor  of  late  years,  the  drainage  being  usually  accomplished  by  tying 
in  a  soft,  red-rubber  catheter  of  large  size  through  a  median  incision 
made  in  the  perineum.  The  floor  of  the  prostate  is  sometimes  cut 
down  a  few  lines  by  a  median  incision,  and  the  bladder  drained  and 
irrigated  with  medicated  solutions.  Many  successful  cases  are  re- 
corded. I  have  operated  a  number  of  times,  occasionally  efCecting  com- 
plete cure,  but  generally  only  producing  palliation  of  the  symptoms. 

The  priority  of  this  operation  is  often  disputed.  Vague  statements 
are  made  that  it  was  done  long  ago,  by  Miche-ange  Aasson,  Eoux, 
Medoro,  a  surgeon  of  Padua,  Borsiori,  Ucelli,  and  others.  But  the 
weight  of  authority  seems  to  credit  the  conception  of  the  operation 
and  its  first  performance  (see  Horovitz*  and  II.  Royes  Bell  f)  to  Bou- 
chardat,  in  1803,  Willard  Parker,  \  of  New  York  (operation  Novem- 
ber 23,  1850),  and  Fergusson,  in  1855,  all  of  wiiom  operated  inde- 
pendently of  any  suggestion  from  the  other.  Then  came  McCraith,  of 
Smyrna,  and  very  many  others. 

Atony  of  the  bladder  is,  as  the  name  implies,  simply  a  lack  of  tone 
in  the  organ.  It  is  muscular  paresis,  and  it  is  to  be  widely  distinguished 
from  paralysis,  an  afl'ection  of  central  and  not  of  local  origin,  with  which 
disease  it  is  commonly  confounded.  Truly,  a  stretched  muscle  which 
will  not  contract  is  paralyzed  ;  but,  to  avoid  confusion,  the  term  atony 
must  be  retained,  paralysis  only  being  applied  where  there  is  nerve- 
lesion.  Every  bladder  suff'ers  in  a  mild  degree  from  what  may  be 
called  physiological  atony  as  the  individual  growls  older.  A  healthy 
boy  can  throw  a  stream  from  his  bladder  to  a  much  greater  distance 
than  he  can  when  he  becomes  an  adult,  even  taking  into  consideration 
the  increased  size  of  the  prostate  and  enlarged  caliber  of  the  urethra, 
and  the  same  remark  holds  true  of  adult  life,  when  compared  with 

*  "Wiener  med.  Wochcnschrift,"  13  and  14,  1883. 

f  London  "  Lancet,"  February  17,  1882,  p.  282. 

X  "New  York  Journal  of  Medicine,"  July,  18")!,  p.  83. 


CHRONIC   (JYSTITIR.  25'3 

healthy  old  age.  The  bladder  being  accustomed  to  a  constant,  slight 
distentipn,  loses  its  expulsive  power  measurably  with  advancing  age. 
Besides  this  mild  condition  of  atony,  however,  there  is  a  pathological 
form  duo  to  overstretching  of  the  muscular  coats,  either  gradual  and 
continued,  or  sudden  and  extreme  (retention),  or  to  constant  congestion, 
as  with  hypertrophied  prostate.  Any  one  may  observe  the  phenomenon 
of  atony  in  his  own  person.  If.  the  urine  be  voluntarily  retained  for 
some  hours  after  the  bladder  is  full  and  the  natural  desire  felt,  it  is 
noticeable,  when  an  opportunity  presents  itself,  and  an  attempt  is  made 
at  passing  water,  that  it  is  necessary  to  wait  some  time,  perhaps  several 
minutes,  before  the  stream  begins  to  flow.  When  it  comes,  it  com- 
mences very  gradually,  and  without  force,  getting  stronger  as  the  flow 
continues ;  finally,  the  last  drops  dribble  slowly  away.  This  is  the 
mildest  pathological  degree  of  atony,  and  is  caused  by  a  paresis  of 
the  overstretched  detrusor  urinse.  In  men  of  sedentary  habits,  or  those 
engrossed  by  absorbing  occupations  (students,  actors),  where  the  calls 
of  nature  are  habitually  disregarded,  this  slight  degree  of  atony,  often 
reproduced,  may  finally  lead  to  a  permanent  lack  of  the  expulsive 
power.  Sometimes  actual  retention  may  come  on,  starting  involuntary 
retention,  the  bladder  having  lost  its  tone  so  far  as  to  refuse  to  contract 
when  an  opportunity  oft'ers.  Passing  water  habitually  in  the  recum- 
bent position,  while  lying  in  bed,  is  believed  to  be  an  occasional  cause 
of  atony.  Predisposing  circumstances  are  general  weakness  and  laxity 
of  the  body.  In  some  cases  there  seems  to  be  an  actual  predisposition 
to  this  condition,  while  in  others  fatty  atrophy  may  induce  it. 

The  form  of  atony  occurring  with  hypertrophied  prostate  does  not 
necessarily  depend  upon  mechanical  overstretching.  It  is  due  to  the 
constant  congestion  of  the  hypertrophied  muscular  coats  of  the  bladder, 
kept  up  by  the  obstacle  to  the  return-flow  of  venous  blood  from  the 
bladder-walls,  formed  by  the  size  of  the  prostate.  With  this  cause,  a 
certain  degree  of  continual  distention  of  the  bladder-walls  often  goes 
hand  in  hand,  and,  where  there  has  been  retention,  this  circumstance 
takes  its  place  as  the  most  prominent  cause. 

Often,  atony  from  overstretching  owes  its  origin  to  retention  of 
urine  occurring  in  the  course  of  acute  disease  (typhoid,  variola),  or 
temporary  loss  of  sensibility  (coma,  concussion,  compression)  not  rec- 
ognized and  relieved  ;  or,  most  frequently,  to  retention  complicating 
stricture  in  the  young,  enlarged  prostate  in  the  old.  Nervous  influence 
has  no  necessary  connection  with  atony.  The  injury  is  mechanical ;  the 
overstretched  detrusor  urinas  loses  its  power,  and  is  unable  to  expel  the 
urine. 

Symptoms. — The  symptoms  of  this  affection  have  been  considered 
under  the  heads  of  its  most  constant  causes,  stricture  and  prostatic 
hypertrophy.  To  recapitulate  for  all  cases  :  in  complete  atony,  the 
expulsive  power  of  the  bladder  being  lost,  the  viscus  fills  up,  and  we 


254  DISEASES  OF  THE  BLADDER. 

liave  the  condition  named  by  Civiale  "  stagnation  with  overflow."  The 
excess  of  urine,  after  the  bladder  has  held  all  that  it  can  as  a  passive 
sac,  flows  over,  ujion  some  muscular  eifort  of  the  jiatient  (sneezing, 
violent  coughing,  laughter),  or  trickles  })assively  away.  In  numy  of 
these  cases  of  stagnation  with  overflow,  the  bladder  is  patient,  and 
holds,  perhaps,  two  or  three  pints  constantly,  without  giving  its  owner 
any  considerable  uneasiness.  What  little  excess  collects  over  this 
amount  occasions  the  normal  desire  to  urinate.  This  is  elTected  by 
voluntary  contraction  of  the  diai)hragin  and  abdominal  muscles,  and 
perhaps  an  ounce  or  more  of  fluid  is  ejected  in  a  dribbling  stream. 
This  brings  relief  for  an  hour,  when  the  elTort  is  repeated,  with  a  like 
result.  Such  patients  arc  ai)t  to  complain  that  their  bladder  is  so  small 
that  it  will  only  contain  a  few  droi)s  of  urine,  after  the  collection  of 
which  they  are  obliged  to  empty  it,  which  they  believe  they  do.  Par- 
ticularly are  these  frcciuent  calls  pressing  if,  as  is  very  apt  to  be  the 
case,  there  is  some  cystitis  along  with  the  atony. 

All  the  signs  of  an  overdisteuded  bladder  are  present  with  complete 
atony.  The  crucial  test  is  the  introduction  of  a  catheter.  As  soon  as 
the  eye  of  the  instrument  reaches  urine,  the  flow  through  the  tube  com- 
mences. It  does  not  spurt  out  as  from  a  normal  bladder,  but  drops 
down  nearly  peri^endicularly  from  the  end  of  the  instrument.  A  cough 
or  a  long  breath  will  make  it  flow  faster,  as  will  also,  very  materially, 
pressure  of  the  hand  over  the  hypogastrium. 

Treatment. — The  object  of  treatment  of  atony  is  to  attcmjot  to 
restore  contractile  power  to  a  muscle  Avhich  has  been  overstretched. 
The  first  indication  is,  obviously,  to  keep  the  muscle  from  any  further 
violence,  by  catheterization  performed  three  or  four  times  daily.  In  the 
young  we  may  always  hope  for  a  cure  ;  in  middle  age  for  amelioration  ; 
but  in  old  age  with  enlarged  prostate  the  injured  muscle  rarely  recov- 
ers its  tone — nor,  indeed,  is  it  always  desirable  that  it  should  do  so. 

Besides  keeping  the  bladder  from  being  again  distended,  avc  have  a 
very  effective  means  of  hastening  the  return  of  the  contractile  power  by 
the  employment  of  cold  injections  into  its  cavit}^  If  there  be  much 
cystitis  with  the  atony,  the  cold  should  be  used  sparingly,  but  otherwise 
the  bladder  should  be  filled  at  each  sitting  Avith  several  successive 
injections,  commencing  at  the  first  sitting  with  water  of  90^  Fahr.,  after 
this  has  flowed  out,  following  with  water  at  85°  Fahr.,  and  a  third  time 
at  the  same  temperature — never  more  than  four  ounces  of  fluid  being 
tiirown  in  at  one  injection.  The  w'ater  may  be  retained  from  one  to  two 
minutes,  and  then  be  allowed  to  drain  off.  This  process  may  be  repeated 
daily,  starting  at  a  temperature  5°  Fahr.  lower  at  each  sitting  and  pro- 
ceeding as  directed  above.  "Water  may  be  injected  as  low  as  40°  Fahr., 
but  it  should  be  allowed  to  run  out  again  immediately.  It  acts  as  a 
local  douche,  but  is  useful  in  youth  and  middle  life  only.  This  treat- 
ment may  be  continued  for  months,  and  it  wmII  yield  good  results  if 


PARALYSIS.  255 

any  such  arc  possible.  The  cold  douche  ai)i)licd  to  tlie  hypogastrium, 
sacrum,  and  perinaeum,  is  a  good  adjuvant  to  the  injections.  Local  ap- 
plications of  electricity  may  also  be  employed,  an  insulated  electrodo 
being  carried  into  the  bladder,  and  the  current  passed  directly  through 
its  walls  to  the  other  electrode  in  the  rectum,  or  to  a  moistened  elec- 
trode over  the  hypogastrium.  No  internal  medication  is  of  any  serv- 
ice, unless  jDOSsibly  a  mild  alkali  to  keep  the  urine  from  exciting  cys- 
titis, or  perhaps  a  little  cantharides,  strychnine,  or  ergot,  for  its 
specific  effect.  Tonics  and  general  hygiene  may  be  necessary  in  spe- 
cial cases. 

PARALYSIS  OF  THE  BLADDER. 

As  atony  is  common,  so  is  true  paralysis  of  the  bladder  uncommon. 
It  occurs  only  in  connection  with  nerve-lesion,  or  rarely  as  a  functional 
nervous  affection  (reflex  urinary  paralysis,  Brown-Sequard).  The 
causes  of  paralysis  of  the  bladder  are  brain  disease  attended  by  hemi- 
plegia (rare),  partial  paralysis  from  reflected  peripheral  nervous  irrita- 
tion acting  through  the  spine  (exceedingly  unfrequent),  any  disease 
or  affection  of  the  spinal  cord  (inflammatory,  apoplectic,  syphilitic, 
cancerous,  from  pressure.  Pott's  disease,  fracture  of  spine,  tumor), 
especially  if  such  spinal  disease  be  attended  by  paraplegia,  partial  or 
complete.  This  latter  set  of  causes,  which  may  be  summed  up  in  the 
one  word  paraplegia,  is  by  far  the  most  active  and  efficient.  Vesical 
paralysis  may  come  on  gradually,  as  sometimes  in  Pott's  disease  and 
in  certain  syphilitic  paraplegi^e,  or  (most  commonly)  suddenly.  In 
the  former  case  the  bladder  discharges  its  contents  from  day  to  day 
more  feebly,  the  change  taking  place  perhaps  so  gradually  that  the 
patient  does  not  notice  it.  Soon  some  of  the  urine  is  retained,  only 
an  excess  over  a  certain  fixed  quantity  being  voided.  This  residuum 
goes  through  the  changes  of  stagnating  urine,  and  by  decomposing 
lights  up  cystitis,  the  more  readily  on  account  of  the  weakened  state 
of  the  bladder-walls  due  to  impaired  innervation.  The  patient  now 
notices  that  his  urine  smells  foul,  is  more  or  less  muddy,  perhaps 
full  of  thick,  ropy  mucus,  and  that  he  has  frequent  calls  to  urinate. 
Perhaps  the  paralysis  may  go  no  further,  but  the  cystitis  will  continue 
to  be  steadily  progressive  unless  arrested  by  appropriate  treatment. 
On  the  other  hand,  the  paralysis  may  go  on  to  become  complete,  when 
retention  will  at  once  appear.  Very  rarely  there  is  paralysis  of  all  the 
muscles,  and  true  incontinence  results  ;  but  this  is  so  exceptional  that 
it  may  be  said  not  to  occur.  Most  commonly,  as  the  paraplegia  comes 
on  suddenly,  so  also  does  the  vesical  paralysis,  and  a  bladder,  at  a 
given  moment  perfectly  healthy,  becomes  at  once  incapable  of  con- 
traction. Eetention  ensues,  the  urine  overdistends  the  bladder  and 
then  overflows,  dribbling  away.     The  bladder  becomes  inflamed  by 


256  DISEASES   OF  THE   BLADDER. 

the  decomposing  retaiiuHl  urine  ;  pns,  stringy  nincns.  earthy  plios- 
phates,  vibriones,  triple-])hosphate  crystals  abound.  The  weakened 
bladder-walls  may  ulcerate  extensively,  or  become  incrustcd  with 
earthy  salts,  or  stone  may  form.  It  is  in  some  such  deplorable  condi- 
tion as  this  that  the  bladder  usually  first  receives  surgical  notice  and 
attention,  whereas  the  whole  list  of  symptoms  might  have  been  avoided 
(except  the  loss  of  contractile  power)  by  the  application  of  the  proper 
means  at  the  proper  time. 

Treatment. — When  a  patient,  from  any  cause,  becomes  wholly  or 
partly  paraplegic,  his  bladder  should  not  be  allowed  to  become  dis- 
teniled.  The  catheter  should  be  passed  soon  after  the  accident,  and 
reintroduced  three  or  four  times  daily,  always  with  great  care,  on 
account  of  the  insensibility  of  the  parts,  and  the  danger  of  lighting 
up  cystitis  mechanically.  At  the  same  time  the  bladder  should  be 
thoroughly  washed  out  with  warm  water  once  or  twice  after  each  intro- 
duction of  the  catheter.  Colder  water  may  be  used  later,  but  this 
remedy,  so  useful  in  atony,  has  little  power  over  true  paralysis  of  the 
bladder  ;  on  the  contrary,  it  may  do  harm.  Warm  water  is  used  sim- 
ply for  purposes  of  cleanliness,  to  take  away  the  ferment,  mucus,  and 
to  prevent  cA'stitis.  This  can  be  done,  probably,  in  every  case  that 
is  properly  managed.  Ordinary  tar  water  used  for  irrigation  some- 
times yields  admirable  results  in  averting  cystitis, 

AVhere  the  patient  is  not  seen  until  stagnation  and  overflow  have 
occurred,  it  is  more  diflficult  to  keep  down  the  inflammatory  outbreak, 
but  the  sooner  it  is  attempted  the  more  chance  is  there  of  success. 
After  catarrh  of  the  bladder  has  become  thoroughly  established,  the 
treatment  becomes  mainly  palliative,  but  even  here  much  can  be  done 
by  the  systematic,  regular  use  of  the  catheter,  Avith  thorough  washing 
of  the  bladder,  first  with  warm  water,  and  then  with  borax,  or  other 
mildly  stimulating  injection,  as  directed  in  cases  of  catarrh,  with  atony 
and  enlarged  prostate. 

Chronic  cystitis  being,  as  has  been  shown,  a  secondary  disease,  the 
main  reliance  of  treatment,  in  any  case,  consists,  after  the  removal  of 
the  cause,  in  the  surgical  measures  already  enumerated,  injections  into 
the  bladder,  medicated  or  otherwise,  position,  and  external  counter- 
irritation.  The  tercbinthinate  and  stimulating  diuretic  drugs  habitu- 
ally employed,  though  of  service  in  certain  selected  cases,  are  of  far 
inferior  importance.  The  value  of  these  drugs  is  secondary,  and  is 
greatly  overrated  by  the  profession  ;  they  do  more  good  as  diluents 
than  by  any  specific  virtue,  and,  being  generally  combined  with  ano- 
dA^nes,  the  rei^utation  which  they  enjoy  is  really  more  often  due  to 
virtues  of  these  latter  than  to  any  special  power  of  their  own  in  con- 
trolling vesical  symptoms. 


PNEUMATURIA.  257 

PNEUMATURIA. 

Pueumatnria  is  one  of  a  number  of  names  given  to  a  malady  in 
which  air,  or  an  odorless  gas  much  like  air,  escapes  from  tlie  urethra 
when  it  has  not  been  introduced  into  the  bladder  by  a  catheter,  and 
when  there  is  no  vesico-intestinal  fistula.  I  brought  the  subject  before 
the  profession  in  America*  in  1882,  recording  two  cases.  In  one  I 
had  a  post-mortem  examination,  and  found  no  communication  with 
the  intestine.  In  the-  other  there  may  have  been  such  a  communica- 
tion. The  patient  is  since  dead,  and  I  could  not  obtain  an  autopsy. 
The  last  of  these  patients  had  no  sugar  in  his  urine  ;  in  the  first  case 
I  did  not  look  for  it.  Eecently  I  have  had  another  case  without  sugar 
— a  gentleman  with  prostatic  disease,  who  uses  a  catheter.  Occasion- 
ally, he  passes  gusts  of  air  by  the  urethra. 

Eizat  f  states  that,  in  Chopart's  edition  of  1855,  annotated  by 
Segalas,  there  are  two  cases — one  a  farmer  in  good  health,  who  had 
no  other  malady  than  that  of  passing  wind  by  the  urethra  ;  the  other 
an  architect  of  seventy,  who  passed  gas  each  time  that  Segalas  sounded 
him.  The  symptom  disappeared  when  the  urine  became  acid.  Brierre 
de  Boisemont  J  refers  to  Eibes's  case  in  the  "Miscellanea  curiosa," 
p.  85,  of  an  infant  ''qui  n'avait  pour  toute  maladie  que  cette  emis- 
sion de  gaz" — the  urine  being  healthy.  Eaciborski's  case  in  Bou- 
chut's  treatise,  "Du  Nevrosisme,"  *  is  an  excellent  one  in  point. 
Finally,  an  exhaustive  consideration  of  the  subject  appeared  from  the 
pen  of  F.  Guiard,  ||  who  comes  to  the  conclusion  that  the  malady  is  a 
fermentation  of  saccharine  urine  within  the  bladder,  since  he  had  seen 
several  patients  who  passed  gas,  and  whose  urine  contained  sugar. 
This  may  be  so.  I  never  have  seen  the  malady  except  in  a  patient 
who  used  the  catheter,  and  I  have  not  excluded  sugar  in  the  only  case 
in  which  I  had  an  autopsy.  It  is  then  quite  possible  that  the  germ 
of  fermentation  is  introduced  by  the  catheter,  and  that  where  sugar 
is  present  gas  is  formed,  which  escapes  later  spontaneously  or  through 
the  catheter.  In  1884  C.  Alem,  in  a  Parisian  thesis,  considers  the 
subject,  but  adduces  nothing  new. 


HETEROLOGOUS  DEPOSITS  AND  TUMORS  IN  THE  BLADDER-WALLS. 

These  are  tubercle,  fibroma,  cyst,  cancer  (epithelioma,  carcinoma), 
sarcoma,  enchondroma;  benign  tumors  like  myoma;  myxoma  has  been 
found  ;  finally,  papilloma  (villous  growth). 

*  "Pneumo-uria,"  "Medical  News,"  December  16,  1882,  p.  675. 
f  "  Journ.  de  Med.  de  Paris,"  February  24,  1883,  p.  209. 

X  "Thfese  de  Paris,"  No.  201,  1825,  p.  15. 

*  Second  edition,  Paris,  ISYY,  p.  245. 

|]  "Ann.  des  Maladies  dcs  Organes  Genito-Urinaires,"  1SS3,  pp.  243,  255,  and  363. 

17 


258  DISEASES  OF  THE  BLADDER. 

These  different  new  formations  cause  symptoms  more  or  less  severe 
according  to  their  situation  and  size.  Thus,  by  pressure  on  a  ureter, 
they  may  lead  to  distention  of  that  canal  and  of  the  pelvis  of  the  kid- 
ney, with  (possibly)  linal  rupture  of  one  or  the  other,  or  atrophy  of 
the  secreting  portion  of  the  kidney.  Again,  the  growth  may  be  near 
the  neck  of  the  bladder,  presenting  an  obstacle  to  the  escape  of  urine, 
which  may  even  lead  to  complete  retention  ;  while,  on  the  other  hand, 
if  it  springs  from  tlie  fundus  away  from  tiie  sensitive  ]iortions  around 
the  neck,  it  not  only  does  not  oppose  any  obstruction  to  the  free  out- 
flow of  urine,  but,  in  exceptional  cases,  may  give  rise  to  little  if  any 
cystitis.  Some  of  these  tumors,  again,  become  engorged  with  blood 
from  motion  or  other  cause,  and  then  all  the  symjitoms  are  aggravated. 
When  a  free  flow  of  blood  takes  place,  the  symptoms  remit  and  the 
patient  feels  better.  The  above  remarks  apply  to  the  whole  category 
of  foreign  growths  taken  together,  and  to  no  particular  class. 

Tubercle. — Tubercle  of  the  bladder  does  not  occur  as  an  isolated 
affection.  It  is  not  very  often  encountered  in  connection  with  pul- 
monary tuberculosis,  but  comes  on  more  frequently  with  tubercular 
ulcerations  of  the  intestines,  and  is  especially  common  with  similar 
disease  of  the  kidney  or  prostate,  or  even  with  advanced  tubcrculariza- 
tion  of  the  testicle,  cord,  and  epididymis.  The  glands  and  follicles, 
usually,  near  the  neck  of  the  bladder  and  orifices  of  the  ureters  first 
suffer.  Groups  of  little  whitish  elevations,  surrounded  by  a  red  areola, 
may  be  seen  at  first,  and  these,  going  on  to  increase,  coalesce  and  break 
down  into  cheesy  degeneration  and  ulceration,  sometimes  leading  to 
perforation  of  the  bladder. 

The  diagnosis  is  mainly  made  by  exclusion.  The  bladder  symp- 
toms are  simply  those  of  chronic  cystitis,  more  or  less  severe  according 
to  the  situation  of  the  deposit.  There  is  rarely  much  blood  in  the 
urine.  The  exploring  sound  may  sometimes  detect  the  ragged  ulcera- 
tions, and  appreciate  the  thickening  of  the  bladder-walls.  Beyond 
this,  exploration  is  usually  negative ;  no  tumor  is  felt  either  by  the 
sound  in  the  bladder  or  by  rectal  or  hypogastric  palpation  ;  while  the 
debris  of  tissue  found  in  the  urine  has  no  distinctive  characters.  The 
diagnosis  usually  rests  upon  the  general  condition  of  the  patient,  and 
the  state  of  the  whole  geni  to-urinary  apjaaratus.  Advanced  i)hthi6ical 
disease  elsewhere,  of  the  lungs,  intestines,  etc.,  but  particularly  of  the 
epididymis,  with  a  ridgy,  knobbed  feel  of  the  seminal  vesicle  and  vas 
deferens  of  the  same  side,  especially  if  there  is  evidence  of  prostatic 
trouble,  and,  above  all,  any  suspicion  of  tubercular  pyelitis — any  of 
these  concurring  symptoms  makes  the  diagnosis  probable,  while  all  of 
them  would  make  it  certain.  Tubercular  geni to-urinary  disease  occurs 
most  frequently  in  youth  and  early  adult  life. 

Treatment. — The  treatment  is  the  same  as  for  phthisis  elsewhere — 
j)roper  warmth,  fatty  food,  fresh  air,  out-door  life,  tonics,  etc.     Lo- 


TUMORS— CYSTS— CANCER.  259 

cally,  anodyne  suppositories,  if  pain  be  great,  rest,  alkaline  diluents  ; 
finally,  syringing  the  bladder  with  warm  water  occasionally,  unless 
the  introduction  of  the  instrument  produces  too  great  pain.  These 
patients  rarely  recover,  but  they  continue  to  live  sometimes  far  beyond 
expectation. 

Fibrous  Tumors. — These  tumors  are  not  common,  but  occasion- 
ally one  or  more  of  them  are  found  in  the  bladder,  where  they  give 
rise  to  trouble  mechanically,  being  perfectly  benign  in  character,  com- 
posed of  connective-tissue  elements,  growing  in  and  from  the  submu- 
cous connective  tissue.  They  appear  first  as  slight  elevations.  These 
enlarge  and  grow  into  the  cavity  of  the  bladder,  sometimes  becoming 
pediculated.  They  are  to  be  distinguished  from  the  irregular  poljrpoid 
overgrowths  from  the  posterior  urethral  orifice  of  the  prostate,  and 
from  supernumerary  prostatic  tumors. 

Syynptoms. — Careful  sounding  with  a  Thomj)son's  searcher,  or, 
perhaps  better,  a  lithotrite,  may  detect  the  position,  size,  and  perhaps 
the  number  of  the  tumors.  The  amount  of  cystitis  is  usually  not  so 
great  as  in  tubercle,  while  the  cachexia  and  occasional  jirofuse  bleed- 
ing of  cancer  are  wanting.  Children  and  young  adults  are  most  liable 
to  be  affected.  With  Nitze's  cystoscope  tumors  of  the  bladder  may 
be  plainly  seen.  The  latest  improvement  of  the  instrument*  gives  a 
field  a  little  lai'ger  than  a  silver  dollar,  and  with  its  use  the  inside  of 
the  bladder  may  be  plainly  seen.  Nitze  indorses  only  the  instrument 
made  by  P.  Hartwig. 

Treatment  is  palliative — alkaline  laxatives,  anodyne  suppositories 
if  necessary,  warm  washing  of  the  bladder,  use  of  catheter,  etc.,  and, 
in  suitable  cases,  suprapubic  cystotomy  and  removal  of  the  tumors. 

Cysts  are  rare  in  or  around  the  bladder,  but  occasionally  they  are 
found.  They  sometimes  contain  bone,  teeth,  muscle,  and  hair,  which 
occasionally  find  their  way  by  ulceration  into  the  bladder,  and  consti- 
tute nuclei  for  stone,  or  give  rise  to  pilimiction.f  Hydatid  as  well  as 
simple  cysts  have  been  encountered.  A  striking  case  of  cyst  of  the 
bladder  is  reported  by  Knox,  operated  on  by  Listen.  J  Diagnosis  was 
made  by  a  catheter,  which  was  being  passed  for  retention.  The  in- 
strument struck  against  a  soft,  movable  mass  at  the  neck  of  the  blad- 
der. Liston  decided  to  perform  epic3'Stotomy  at  once,  and  removed, 
a  large  cyst  very  like  the  bladder  in  volume,  form,  and  appearance. 

Cancer  is  rare  in  the  bladder,  but  still  it  is  more  common  than 
benign  forms  of  tumor,  or  other  foreign  growths  not  inflammatory. 
It  may  originate  in  \h&  bladder,  but  more  often  is  an  extension  of  dis- 
ease from  the  prostate  or  bowel.  When  occui^yiug  the  bladder  it  may 
grow  from  any  portion  of  the  walls,  but  usually  springs  from  near  the 

*  "Berl.  klin.  TVchnschrft.,"  Feb.  21,  1SS7. 

f  "  ilemoire  de  la  Soc.  de  Biologie,"  1S50,  Raver. 

X  "Medical  Times,"  August  2,  1862,  p.  104. 


260  DISEASES  OF  THE  BLADDER. 

neck  or  orifices  of  the  ureters.  Different  varieties  of  cancerous  growth 
liave  been  enconntered.  The  encei)haloid,  or  soft  sarcoma,  is  not  very 
uncommon.  Seirrhus  and  the  epithelial  disease  are  also  more  often 
observed  ;  colloid  occurs.  The  cancerous  nodules  develop  under  the 
mucous  membrane  in  the  walls  of  the  bladder,  and  often  grow  to  the 
formation  of  a  considerable  tumor.  Ence])haloid,  especially,  may 
grow  out  in  a  fungous  manner,  until  it  fills  the  whole  cavity  of  the 
bladder.  Cancerous  growths  go  through  the  same  i>hases  here  as  else- 
where, finally  ulcerating  and  destroying  life  by  loss  of  blood  or  ca- 
chexia, or  wearing  out  the  patient  by  extreme  pain. 

The  symptoms  vary  but  little  from  those  of  other  tumors.  There 
may  be  the  same  mechanical  obstruction  to  the  escape  of  urine,  due  to 
the  position  of  the  growth,  and  calling  for  the  use  of  the  catheter,  the 
same  cystitis,  more  or  less  intense,  according  to  the  position  and  size 
of  the  tumor  and  the  extent  of  ulceration  ;  but  in  several  particulars 
the  symptoms  of  cancer  in  the  bladder  are  special,  and  the  diagnosis 
more  easy  than  for  other  tumors.  The  pain  is  more  severe,  is  referred 
to  the  back,  loins,  and  thighs,  as  well  as  to  the  pubic  and  perineal 
region  ;  enlarged  glands  may  sometimes  be  felt  along  the  brim  of  the 
pelvis.  The  bleeding  is  usually  intermittent  in  character ;  at  first 
there  may  be  long  intervals  of  months  between  the  paroxysms.  The 
blood  flows  suddenly  and  profusely,  in  clots  and  fluid,  attended  by 
great  pain.  After  each  bleeding  the  severity  of  the  symjitoms  lessens. 
Between  the  attacks  there  is  more  or  less  oozing,  sometimes  enough 
to  keep  the  urine  constantly  red  ;  sometimes,  during  the  earlier  months 
of  the  disease,  only  to  be  detected  by  the  microscope.  Tlie  introduc- 
tion of  a  catheter  is  very  apt  to  occasion  haemorrhage,  and  should  be 
avoided  as  much  as  possible.  Sometimes  shreds  of  tissue,  projecting 
from  the  borders  of  an  ulcerated,  cancerous  nodule,  will  be  caught 
in  the  eye  of  the  catheter,  and  be  pulled  away.  The  microscopic 
examination  of  such  shreds  may  sometimes  throw  light  upon  the 
nature  of  the  tumor.  In  the  middle  and  later  stages  of  the  disease 
the  cancerous  cachexia  may  be  marked,  and  the  bleeding  more  con- 
stant and  profuse,  while  the  intervals  between  the  paroxysms  will  be 
shorter.  Finally,  in  seirrhus,  the  hardness  can  be  felt  by  the  finger 
in  the  rectum,  and  in  the  common  form  of  cancerous  disease,  medul- 
lary, the  size  which  the  mass  attains  renders  it  nearly  always  easy  of 
detection  long  before  it  has  advanced  far  enough  to  be  fatal.  This 
growth  has  been  mistaken  for  enlarged  prostate.  Its  general  size, 
shape,  and  position  may  be  studied  out  with  the  searcher,  while  the 
finger  in  the  rectum  will  sometimes  recognize  a  peculiar,  soft,  semi- 
elastic  tumor  behind  the  jirostate,  and  be  able  to  appreciate  pressure 
made  upon  the  tumor  above  the  pubis.  Cancer,  here  as  elsewhere,  is 
a  fatal  disorder.  The  treatment  is  mainly  symptomatic  and  jmlliative, 
keeping  up  strength  by  all  known  tonic  and  hygienic  means,  and  using 


CANCER.  201 

the  same  sedative  and  local  treatment  as  for  other  tumors  of  the  blad- 
der, emioloying  special  means  as  they  are  required  by  special  cases. 
Opium  ranks  first  in  usefulness. 

The  question  of  the  propriety  of  operation  naturally  comes  in  here. 
Much  has  been  written  of  late  about  tumors  of  the  bladder,  notably 
the  monographs  of  Stein,*  Thompson,!  Kuster,J  and  Guyon.*  The 
revival  of  suprapubic  cystotomy  has  given  new  impetus  to  opera- 
tive interference  with  the  bladder,  explorative  and  otherwise.  The 
high  operation  is  always  justifiable  in  the  case  of  benign  tumors.  My 
experience  in  their  removal  has  been  happy.  ||  Thompson  advocates 
the  perineal  method,  but,  however  good  this  may  be  for  exploratory  pur- 
poses, it  certainly  does  not  compare  favorably  with  the  suprapubic 
method  when  anything  positive  is  to  be  done,  or  even  for  exploration. 
Yet  many  successful  extirpations  of  benign  tumors  have  been  per- 
formed by  both  methods. 

When  the  question  is  the  removal  of  cancer,  then  it  is  probably 
better  to  confine  operative  interference  to  palliation.  Much  comfort 
can  be  given  in  these  cases  after  they  become  obstructive  by  growing 
into  the  orifice  of  the  urethra  by  a  median  perineal  section,  extensive 
scraping,  and  wearing  a  tube  tied  in.  I  have  so  operated  a  number  of 
times.  .  Or  a  suprapubic  operation  may  be  made,  and  the  growth  be 
extensively  scraped,  drainage  being  carried  on  by  a  permanent  soft 
tube  worn  above  the  pubis.  When  in  a  case  of  vesical  cancer  it  is 
decided  to  make  permanent  drainage  for  the  relief  of  symptoms,  I 
believe  that  this  drainage  gives  more  comfort  when  effected  by  a  tube 
worn  permanently  above  the  pubis  (p.  129). 

Many  efforts  have  been  made  to  resect  portions  of  the  bladder. 
Dogs  were  first  successfully  experimented  on.  On  January  7,  188.2, 
Dr.  Fisher  brought  up  the  subject  in  the  Society  of  Physicians  at 
Buda-Pesth,  stating  that  the  operation  had  been  done  by  Pott,  Chopart, 
and  Desault,  but  then  abandoned.  Fisher  narrated  his  experiments  on 
eight  dogs,  and  advocated  the  operation  in  certain  cases. 

Sonnenburg,'^  of  Berlin,  excised  suprapubically  the  entire  bladder, 
except  a  portion  of  the  posterior  wall,  the  trigonum,  and  orifices  of  the 
ureters  and  the  sphincter  (opening  the  peritoneum),  in  a  woman  of 
sixty.  He  drained  through  the  urethra  and  abdominal  incision,  and 
when  the  case  was  reported  after  three  weeks  it  was  doing  well,  but  a 
few  weeks  later  the  patient  died  of  exhaustion. 

*  "Tumors  of  the  Bladder,"  William  Wood  &  Co.,  New  York,  1881. 
f  "  Tumors  of  the  Bladder,"  Churchill,  London,  1884. 

■[  E.  Kiister,  "  Volkmann's  Sammlung  klinischer  Vortrage,"  "  Ueber  Harnblasen-Ge- 
sehwiilste,"  etc.,  pp.  267,  268,  1886. 

*  "Sur  la  Diagnostic  et  le  Traitement  des  Tumeurs  de  la  Vessie,"  "Ann.  des  Mai. 
des  Organes  Genito-Urinaires,"  November,  1886,  p.  651. 

II  E.  L:  Keyes,  "New  York  Medical  Record,"  May  28,  1887. 
^  "Berl.  klin.  Wochenschrift,"  No.  52,  1884. 


262  DISEASES   OF   THE   BLADDER. 

Autal  removed  by  the  suprapubic  operation  onc-tliird  of  the  blad- 
der of  a  mail  of  sixty-one  extra-peritoneally,  iiicludiiif]:  a  tumor  thereon 
attached  (the  nature  of  the  tumor  is  not  stated  in  the  "  Centralbhitt").* 
The  bhidder  was  sutured,  and  the  patient  rej)ortcd  as  holding  water 
three  to  four  hours  seven  weeks  after  the  operation. 

rapiUoma  {ViIIuus  Growtli). — This  tumor  may  be  partly  hard, 
with  villi  (yet  benign  and  pedunculated),  or  a  velvety,  flat  set  of  villous 
tufts.  Villi  are  also  found  upon  a  carcinomatous  base.  Villous 
growth,  papillomatous  or  otherwise,  is  not  very  uncommon.  It  is  a  soft, 
pulpy  body,  which  may  grow  to  be  as  large  as  a  small  orange.  I  have 
successfully  removed  one  such  by  suprapubic  section.  It  is  consti- 
tuted by  innumerable  villi,  which  branch  otf  in  every  direction,  are 
attached  to  the  submucous  connective  tissue  of  the  bladder,  are  iden- 
tical in  structure  with  the  villi  of  the  healthy  chorion,  and  are  exceed- 
ingly vascular.  Several  tumors  may  co-exist  in  a  single  bladder,  or  a 
portion  of  bladder-surface  may  be  found  velvety,  from  being  covered 
by  small  villous  processes  similar  to  those  on  the  tumor.  The  most 
usual  site  for  these  tumors  is  the  base  of  the  trigone,  between  the 
orifices  of  the  ureters.  There  is  nothing  cancerous  about  their  struct- 
ure. Their  cause  is  unknown.  They  never  lead  to  secondary  cancer- 
ous deposits  elsewhere.  They  do  not  spontaneously  ulcerate.  The 
lymjihatic  glands  are  not  implicated.  There  is  no  characteristic 
cachexia.  "When  they  kill,  death  seems  due  purely  to  loss  of  blood 
and  exhaustion  from  pain. 

The  symptoms  of  villous  growth  are  like  those  of  other  vesical 
tumors,  except  that  they  are  less  often  obstructive,  and  that  the  urine 
has  blood  in  it  almost  constantly.  No  tumor  can  be  felt,  as  the  mass 
is  too  soft  to  be  recognized  either  by  the  finger  in  the  rectum  or  the 
searcher  in  the  bladder.  Sounding  almost  invariably  aggravates  the 
symptoms,  and  gives  rise  to  a  fuller  supply  of  fresh  blood.  Shreds 
of  the  tissue  sometimes  come  away  with  the  urine,  and  may  show 
characteristic  appearances  under  the  microscope.  The  structure 
of  the  growth  is  simply  an  enormously  wide,  thin-walled  vessel, 
curved  on  itself  to  form  a  loop,  and  covered  by  three  or  four  layers 
of  cylindrical  epithelium,  seemingly  placed  directly  upon  it.  The 
suffering  is  often  intense,  and  vesical  tenesmus  very  marked.  Nitze 
has  seen  this  form  of  growth  and  diagnosticated  it  by  the  use  of  his 
cystoscope. 

Haematuria  is  the  only  symptom  at  first,  usually  intermittent,  with 
long  intervals.  The  duration  of  the  malady  is  great.  In  the  Museum 
of  St.  George's  Hospital,  London,  there  is  a  specimen  (Series  XII,  No. 
113)  of  solitary  pedunculated  villous  growth  in  a  bladder,  taken  from 
a  man  of  eighty-one,  whose  first  attack  of  hasmaturia  occurred  twenty 
years  before  his  death,  and  who  had  no  new  attack  of  bleeding  until 

*  "  Centralblatt  fiir  Chir.,"  September  5,  1885. 


COMPOSITION   OF   CALCULI.  2C3 

four  years  before  he  died.     Cases  of  eight,  eleven,  fifteen  years'  dura- 
tion arc  very  numerous. 

Treatment. — Without  doubt,  in  any  case  of  villous  tumor,  myxoma 
or  myoma  diagnosticated  or  strongly  suspected,  tlie  suprapubic  explo- 
ration and  removal  is  the  proper  resource.  Rest,  palliation,  and  as- 
tringents are  only  temporary  expedients. 


CHAPTER  XIV. 

STONE  IN  THE  BLADDER  * 


Materials  of  which  Calculi  are  formed.— Causes  of  Stone,  interual  and  external.— Number.— Size.— 
Shape.— Weight.— Degree  of  Hardness. — Possible  Consequences  of  Stone,  including  Symptoms, 
Pathology,  and  Modes  of  Death.— Symptoms  considered  in  Relation  to  Diagnosis  and  Selection 
of  Mode  of  Cure.— Sounding.— Circumstances  prejudicial  to  a  Choice  of  Lithotrity. 

The  presence  of  a  foreign  body  in  the  bladder  is  recognized  by 
common  consent  as  the  cause  of  the  most  painful  suffering  to  which 
humanity  is  liable.  The  foreign  body  in  the  great  majority  of  cases  is 
generated  entirely  within  the  urinary  passages,  most  frequently  in  the 
kidneys  ;  sometimes  it  is  introduced  from  without,  as  when  such  sub- 
stances as  slate-pencils  and  hair-pins  have  been  inserted  into  the 
urethra,  under  the  influence  of  morbid  erotic  impulse,  or  a  bullet,  a 
portion  of  shell,  or  fragment  of  bone,  has  found  its  way  into  the  blad- 
der by  gunshot-wound.  In  either  case  the  result  is  a  concretion  of 
stony  hardness  resulting  from  the  more  or  less  rapid  deposit  or  crys- 
tallization of  the  salts  of  the  urine  upon  a  nucleus,  forming  what  is 
known,  in  common  language,  as  stone  in  the  bladder.  In  ninety  per 
cent  of  cases  of  stone  the  nucleus  has  been  most  probably  an  aggrega- 
tion of  crystals  of  uric  acid,  which,  happening  originally  in  the  kidney, 
has  passed,  with  or  without  attendant  symptoms  of  renal  colic,  into 
the  bladder,  and  failed  to  escape  by  the  urethra.  Of  the  remaining 
ten  per  cent  of  nuclei,  extraneous  substances  constitute,  perhaps,  the 
largest  proportion,  then  blood-clots,  or  other  organic  products,  such 
as  a  mixture  like  mortar,  of  altered,  ropy  pus,  with  a  precipitate  of 

*  Chapters  XIV,  XV,  XVI,  XVII,  and  the  Preface  are  the  only  parts  of  the  first  edition 
of  this  work  wi-itten  by  Dr.  Van  Buren.  The  last  three  of  these  chapters  require  to  be  en- 
tirely recast,  since  lithotrity  is  practically  obsolete,  and  litholapaxy,  its  natural  heir,  demands 
its  place.  Chapter  XIV  I  prefer  to  leave  as  nearly  intact  as  possible.  It  is  an  admirable 
condensation  of  the  subject,  and  as  true  now  as  when  Dr.  Van  Buren  penned  it,  except  as 
to  some  minor  points  in  relation  to  choice  of  a  method  of  cure.  Litholapaxy  had  not  been 
discovei'ed  when  Chapter  XIV  was  written,  but  long  before  his  death  Dr.  Van  Buren  recog- 
nized the  value  of  Bigelow's  operation,  and  adopted  it  in  toto.  I  must  refer  those  who 
desire  my  personal  views  in  regard  to  the  subjects  treated  in  Chapter  XIV  to  my  article 
"  Urinary  Calculus  "  in  the  "  International  Encyclopfedia  of  Surgery,"  vol.  vi,  p.  1-45, 
where  I  have  discussed  them  at  some  length. — E.  L.  Keyes. 


0(54  STONE  IN  THE  BLADDER. 

uriuarj  i^liosphatcs,  or  an  aggregation  of  crystals  of  oxalate  of  lime 
from  the  kidney. 

As  to  the  subsequent  growth  of  the  calculus,  there  is  endless  varia- 
tion, both  as  to  its  rate  of  rapidity  and  the  nature  of  the  materials 
which  serve  for  its  increase.  These  materials,  derived  from  the  saline 
constituents  of  the  urine,  combined  with  an  uncertain  amount  of  ani- 
mal matter — the  secretions  from  the  vesical  mucous  membrane,  pus, 
or  blood — are  deposited  around  the  nucleus  in  concentric  layers  of 
varying  thickness.  As  the  chemical  constitution  of  the  urine  is  liable 
to  constant  change,  the  additions  to  the  bulk  of  the  calculus  are  cor- 
respondingly uncertain.  Calculi  consisting  entirely  of  oxalate  of  lime, 
which  are  rare,  are  slowest  of  growth  ;  next,  those  composed  of  pure 
lithic  acid  ;  while  stones  of  mixed  character,  in  which  the  concentric 
layers  are  formed,  according  to  the  constitution  of  the  urine  prevailing 
at  the  time  of  deposit,  of  lithic  acid  or  oxalate  of  lime,  the  amorphous 
urates,  phosphate  of  lime,  or  the  triple  phosphate  of  ammonia  and 
magnesia,  are  very  common,  and  of  more  rapid  but  uncertain  growth. 
Calculi  composed  mainly  or  entirely  of  the  phosphates  grow  most 
rapidly  and  attain  the  largest  size. 

The  pliosphatic  salts,  always  present  and  held  feebly  in  solution  in 
the  urine  by  an  excess  of  phosj)horic  acid,  are  liable  to  be  constantly 
and  largely  precipitated  in  the  bladder  whenever  any  considerable  por- 
tion of  its  lining  membrane  is  the  seat  of  suppurative  inflammation. 
The  soda  of  the  liquor  pui'is  takes  the  acid  away  from  these  superphos- 
phates, and  the  residual  phosphates  are  thrown  down  at  once,  mostly 
in  the  form  of  an  amorphous  insoluble  powder.  Moreover,  urine  thus 
deprived  of  its  normal  acidity  undergoes  more  jiromptly  putrefactive 
fermentation,  and  the  ammonia,  always  generated  during  this  jorocess, 
effects  its  peculiar  reaction  upon  pus,  when  present,  converting  it  into 
an  adhesive,  ropy,  mucoid  substance,  a  characteristic  ingredient  in  the 
urine  of  so-called  catarrh  of  the  bladder,  to  which,  indeed,  that  form 
of  cystitis  owes  its  name.  Here  we  have  at  once  two  most  important 
factors  in  the  formation  of  vesical  calculus. 

The  remarkable  insolubility  of  lithic  acid,*  and  of  tlie  neutral 
phosphates  as  well,  are  noteworthy  facts  in  connection  with  the  eti- 
ology of  stone.  The  urates  would  rarely  precipitate  or  crystallize  at 
the  temperature  of  the  body,  without  a  nucleus  to  invite  them.  The 
phosphates,  by  the  aid  of  mucoid  pus,  do  so  more  frequently  ;  the 
large  number  of  phosphatic  calculi  often  found  in  the  suppurating 
bladders  of  old  people  would  seem  to  establish  this  fact.  Whatever 
favors  the  generation  of  uric  acid  in  the  organism  would  seem,  there- 
fore, to  serve  in  some  degree  as  a  cause  of  calculous  disease.  Gout 
and  rheumatism,  undoubtedly,  do  this.  According  to  Prout,  lithic 
acid  is  the  essence  of  gout ;  f  and  gouty  subjects  are  notoriously  liable 

*  From  the  Greek  \ldos,  a  stone.  \  Prout  on  "  Stomach  and  Renal  Diseases." 


CAUSES.  20 


)0 


to  gravel  and  calculous  affections  in  all  tlicir  forms.  The  occurrence 
of  stone  in  the  bladder,  in  successive  generations  in  the  same  family, 
is  thus  explained.  A  tendency  to  excess  of  litliic  acid  belongs  also  to 
early  life  ;  it  is  one  of  the  recognized  peculiarities  of  infancy.  Cases 
of  congenital  stone  in  the  bladder  are  on  record.  The  frequency  of 
calculous  disease  in  children  is  thus  explained.  In  Thompson's  table 
of  1,82?  cases  of  lateral  lithotomy,  473,  or  more  than  a  quarter  of  the 
whole,  were  children  under  five  years  of  age.*  At  the  other  end  of 
life,  obstructive  disease,  generally  from  enlarged  prostate,  is  a  frequent 
cause  of  stone  in  the  bladder.  The  conditions  are  highly  favorable  to 
the  formation  of  stone  in  a  patient  suffering  from  enlargement  of  the 
prostate  ;  the  change  in  shape  Avhich  the  bladder  takes  on,  the  catarrh- 
al inflammation  of  its  lining  membrane,  which  almost  inevitably 
sooner  or  later  supervenes,  together  with  the  inability  to  completely 
evacuate  its  contents,  whether  from  the  obstruction  at  its  outlet,  or 
loss  of  contractile  power,  or  both  combined,  all  favor  this  result. 
These  circumstances  would  seem  to  explain  why  vesical  calculus  is 
more  frequently  encountered  at  the  two  extremes  of  life.  In  Civiale's 
table  of  5,376  cases  of  stone  in  the  bladder,  2,314,  or  nearly  one  half, 
were  under  the  age  of  puberty — the  largest  number  at  any  one  year  of 
life  being  321  at  five  ;  while  of  the  remainder,  the  next  highest  num- 
ber, 184,  occurs  at  the  age  of  sixty,  f  Inflammations  affecting  any 
portion  of  the  mucous  membrane  lining  the  urinary  passages  would 
seem  to  favor  the  formation  of  calculous  deposit.  Stricture  of  the 
urethra,  for  this  reason,  and  also  from  its  obstructive  influence,  is  a 
recognized  cause  of  stone.  J  The  influence  of  mineral  ingredients  in 
water  habitually  employed  for  drinking  and  cooking  is  generally  sup- 
j)osed  to  cause  calculous  disease ;  but  of  this  there  is  no  adequate 
proof.  In  certain  regions  of  our  country  stone  is  very  infrequent,  as 
in  JSTew  England  ;  *  while  in  Ohio,  Kentucky,  Tennessee,  North  Caro- 
lina, and  Alabama,  the  disease  is  not  uncommon.  It  is  certainly  very 
rare  in  the  negro.  ||  Without  reference  to  race,  the  same  unexplained 
tendency  to  calculous  disease  exists  in  certain  localities  in  Euroi^e,  as 
in  Norfolk,  in  England,  Wiirtemberg,  and  Moscow ;  while  in  Den- 
mark it  would  seem  to  be  less  frequent.  There  are  no  chemical  or 
meteorological  facts  yet  determined  by  science  concerning  either  water, 
soil,  or  climate,  which  would  justify  an  attempt  to  explain  these  dis- 
crepancies. Disease  of  the  brain  or  spinal  cord,  paralyzing  the  lower 
extremities  and  bladder,  favors  the  formation  of  stone.  Here  inflam- 
mation of  the   bladder,  from  stagnation  and   decomposition  of  the 

*  Thompson's  "  Practical  Lithotomy  and  Lithotrity." 

f  "Traite  de  TAffection  calculeuse,"  Paris,  1838,  p.  646. 

X  I  have  lithotomized  two  adults  who  were  the  subjects  of  stricture. — Van  Bcrex. 

*  Morland,  "  Diseases  of  the  Urinary  Organs,"  Boston,  185-8,  p.  387. 
II  Gross  on  "  Diseases  of  the  Urinary  Organs,"  Philadelphia,  p.  343. 


266  STONE  IX   THE  BLADDER. 

urine,  is  tlie  iranicdiate  exciting  cause.  To  what  extent  the  coexistent 
diminution  of  nerve-power  aids  in  the  process  is  not  so  clear.  There 
is  little  doubt  but  that  the  free  use  of  animal  food  and  nuilt  liquor, 
coincidently  with  excessive  fatigue  and  profuse  sweating,  is  likel}'  to 
cause  a  concentrated  quality  of  urine  prone  to  crystallize  readily, 
especially  in  a  healthy  child,  or  in  an  adult  of  gouty  habit ;  and  it  is 
not  improbable  that  in  a  coincidence  of  favorable  conditions  of  this 
kind  many  cases  of  stone  take  their  origin.  Civiale  expresses  the 
opinion  that  calculous  disease  in  children  not  unfrequently  dates  from 
such  sudden  crystallization. 

Foreign  bodies  introduced  into  the  bladder,  from  without,  become 
incrusted  with  the  salts  of  the  urine  in  an  incredibly  short  sj^ce  of 
time.  A  catheter  left  in  the  bladder  will  show  deposit  on  its  surface 
on  removal  at  the  end  of  forty-eight  hours,  and  the  incrusted  material 
consists  almost  entirely  of  phosiihatic  salts.  Stones  which  take  their 
origin  in  this  manner  always  increase  rapidly  in  size,  and  they  have 
been  met  with  at  all  periods  of  life,  except,  perhaps,  in  very  early 
childhood.  The  late  war  in  this  country  furnished  several  examples 
of  bullets,  fragments  of  bombshells,  etc.,  which  had  penetrated  the 
bladder  and  become  nuclei  of  stones.  Pins,  fragments  of  fish-bones, 
chicken-bones,  and  other  articles  swallowed  as  food  or  by  accident, 
have  found  their  way,  by  ulceration,  from  the  intestines  into  the  blad- 
der, where  they  have  given  origin  to  calculi.  Even  foetal  bones  have 
ulcerated  into  the  bladder  from  the  uterus,  and  pieces  of  wood  and 
bone  have  been  forced  mto  the  bladder  as  the  result  of  accident ;  and, 
finally,  through  recto-vesical  fistuljB,  fruit-seeds,  and  other  hard  ma- 
terials mingled  with  the  contents  of  the  bowel,  have  become  nuclei  of 
vesical  incrustation.  The  most  frequent  cause  of  the  presence  of  ex- 
traneous substances  in  the  bladder  is  to  be  found,  unfortunately,  in 
the  unnatural  gratification  of  the  sexual  desire.  It  may  be  safely 
assumed  that  every  material  substance  that  could  possibly  enter  the 
human  urethra  has  been  used  for  this  purpose,  and  a  certain  propor- 
tion of  articles  so  used  have  found  their  way  into  the  bladder.* 

*  I  removed  a  phosphatic  calculus  of  large  size,  from  a  man  of  sixty-seven,  at  Bcllevue 
Hospital,  in  1847,  which  had  formed  upon  a  head  of  wheat-straw;  and  some  years  later 
I  operated  upon  a  boy  of  seventeen,  at  the  New  York  Hospital,  in  the  center  of  whose 
calculus  was  found  a  piece  of  a  slate-pencil,  an  inch  and  a  half  in  length,  which  he  con- 
fessed to  have  introduced  into  his  urethra  some  years  before,  at  school.  Within  the 
same  year  my  colleague,  the  late  Dr.  John  Watson,  removed  from  a  young  man,  at  the 
same  hospital,  a  phosphatic  calculus  of  a  shape  so  curiously  elongated  as  to  suggest  an 
unusual  nucleus.  On  section  it  was  found  to  contain  a  piece  of  an  ordinary  lead-pencil, 
several  inches  in  length.  I  have  in  my  posses.^ion  a  phosphatic  calculus,  sent  to  me  by 
my  friend  Dr.  Taylor,  of  Memphis,  Tenn.,  removed  from  a  woman,  in  which  the  calculous 
matter  is  deposited  around  a  fragment  of  althea-root,  four  inches  in  length,  and  con- 
verted into  a  brush  at  one  end — an  instrument  used  by  a  certain  class  of  women  for 
brushing  the  teeth  with  snufi — a  practice  not  uncommon  in  some  localities. — Van 
Bdren. 


NUMBER,   SHAPE,   SIZE.  207 

The  short,  direct,  and  capacious  urethra  of  the  female,  which,  by 
affording  to  nuclei  formed  in  the  body  so  ready  an  escape,  renders 
stone  in  the  bladder  a  rare  disease  in  women,  serves  precisely  an  oppo- 
site purpose  under  these  circumstances,  so  that  in  this  class  of  cases 
the  proportion  of  females  is  much  larger,  evidently  because  a  foreign 
body  can  slip  through  the  female  urethra  and  be  lost  in  the  bladder 
much  more  readily  than  through  the  longer  and  more  tortuous  pass- 
age of  the  male.  Hence,  while  in  the  aggregate  we  meet  in  practice 
but  one  case  of  vesical  calculus  in  women  to  twenty  in  men,  it  may  be 
confidently  asserted  that  the  proportion  of  cases  in  which  a  calculus 
has  formed  on  a  foreign  body  introduced  from  without  is  larger  in 
women.  There  are  several  other  forms  of  vesical  calculus  composed 
of  materials  existing  only  exceptionally  in  the  urine,  or  in  quantities 
so  minute  as  to  very  rarely  form  concretions,  such  as  cystine,  xanthine, 
uric  oxide,  silicic  acid,  and  carbonate  of  lime,  for  the  study  of  which 
we  must  refer  to  works  devoted  specially  to  the  chemistry  of  the 
urine.* 

Number,  Shape,  Size,  Weight,  and  Degeee  of  Hardness. 
— Vesical  calculi  are  usually  solitary,  of  a  compressed  ovoidal  shape, 
and  in  size  varying  from  that  of  a  large  pea — just  too  large  to  escape 
by  the  urethra — to  a  magnitude  limited  only  by  the  capacity  of  the 
bladder.  In  weight  and  density  they  vary  according  to  their  chemical 
composition,  the  weight  of  a  calculus  conveying  no  accurate  idea  of  its 
volume.  The  mulberry  calculus,  consisting  of  oxalate  of  lime,  so  called 
because  the  inequalities  of  its  external  surface  sometimes  resemble 
those  of  the  fruit  from  which  it  is  named,  is  the  heaviest  in  proportion 
to  its  volume,  the  hardest,  and  most  dense  in  structure  ;  next  in  order 
of  hardness  and  density  is  the  calculus  of  pure  uric  acid ;  then  the 
composite  calculi,  composed  mainly  of  urates  ;  finally,  the  lightest  of 
all,  and  also  the  most  friable,  the  phosphatic.  The  hardest  stones 
are  more  apt  to  be  solitary,  and  they  are  generally  the  smallest  in  size. 
These  considerations  are  of  practical  value  as  bearing  on  the  availa- 
bility of  the  crushing  operation,  for  there  are  some  calculi  of  oxalate 
of  lime,  and  even  occasionally  one  of  pure  lithic  acid,  so  dense  and 
hard  as  to  resist  the  strength  and  power  of  the  best  constructed  litho- 
trite.  Mulberry  calculi,  nevertheless,  vary  in  hardness,  and  Civiale 
reports  several  cases  in  which  he  crushed  large  calculi  of  this  sort  at 
one  operation,  f  The  length  of  time  during  which  a  patient  may  have 
suffered  from  symptoms  of  stone  affords  no  positive  evidence  as  to  its 

*  Neubauer  and  Vogel,  "  A  Guide  to  the  Qualitative  and  Quantitative  Analysis  of  the 
Urine"  (New  Sydenham  Society),  London,  1863,  and  Thudichum,  "Pathology  of  the 
Urine." 

f  Loc.  cit.,  p.  193.  Sir  Henry  Thompson  also  reports  four  calculi  of  oxalate  of  lime 
in  184  cases  of  stone  treated  by  lithotrity,  "British  Medical  Journal,"  June,  1871,  p.  oTl, 
and  Ivanchich  has  recorded  many  others.  Sechster  Sammelbericht  v.  w.  50  Fallen  v. 
Blasensteinzertriimmerung,  Wien,  IB'ZS. 


2G8  STOXE  IX   THE  BLADDER. 

size,  nor  is  tlie  reverse  of  this  assertion  true ;  for,  as  already  stated, 
mulberry  calculi  and  those  of  lithic  acid  grow  slowly,  and  seem  even 
to  remain  stationary  for  long  periods,  while  those  of  compound  char- 
acter, and  specially  phosphatic  calculi,  gain  size  more  steadily  and 
rapidly.  The  last  two  varieties  include  the  large  majority  of  vesical 
calculi  as  encountered  in  practice  ;  the  stone  consisting  of  pure  lithic 
acid  is  met  with  perhaps  once  in  eight  or  nine  cases,  while  the  mul- 
berry calculus  not  once  in  twenty.  In  considering  the  size  and  hard- 
ness of  vesical  calculi,  it  is  to  be  borne  in  mind  that  they  arc  always 
lighter,  harder,  and  even  somewhat  smaller,  after  removal  from  the 
body  and  thorough  desiccation,  tluui  when  saturated  with  urine  in 
the  bladder. 

A  calculus  may  be  friable  extcrnall}-,  while  its  nucleus  may  prove 
to  be  exceedingly  dense  and  hard.  For  example  :  a  patient  may  have 
carried  a  calculus  of  pure  uric  acid  or  oxalate  of  lime  in  his  bladder 
for  months,  growing  very  slowly,  and  causing  so  little  irritation  as 
to  scarcely  trouble  the  transparency  of  his  urine.  Suddenly,  from 
cold  or  other  causes,  the  vesical  irritation  is  increased  ;  pus  is  formed  ; 
the  phosphates  are  precipitated,  and  the  calculus  begins  to  grow  rap- 
idly from  accretion  of  the  more  friable  phosphatic  salts.  In  crushing 
a  calculus  of  this  kind  its  fragments  would  naturally  give  evidence  of 
different  degrees  of  hardness. 

As  to  multiple  calculi,  while  a  solitary  stone  is  the  rule,  two  may 
possibly  be  encountered  in  every  six  or  eight  cases  as  they  occur  in 
practice,  and  a  larger  number  with  increasing  rarity.  They  are  cer- 
tainly more  common  m  advanced  life,  but  there  are  no  known  con- 
ditions upon  which  their  presence  may  be  predicated.  Plurality  of 
calculi  would  seem  to  result  from  the  somewhat  rapid  and  successive 
generation  of  renal  nuclei  and  their  transmission  to  the  bladder, 
from  the  spontaneous  fracture  of  calculi  in  the  bladder,  which 
occurs  more  frequently  than  is  generally  supposed  ;  *  and  from  the 
influence  of  the  bladder's  contractions  upon  a  soft  magma,  composed 
of  earthy  phosphates  and  altered  mucoid  pus,  which  is  more  or  less 
constantly  present  in  cases  of  chronic  cystitis  from  prostatic  or  other 
obstruction.! 

*  F.  S.  Watson,  of  Boston,  recently  showed  a  striking  case,  with  photographic  illustra- 
tion, of  spontaneous  fracture  to  the  "  Society  for  Medical  Improvement "  in  Boston,  No- 
vember 22, 1886,  referring  to  other  previously  reported  cases — those  of  Ord,  etc.  I  have  the 
photograph  and  history.     Dr.  Watson  could  not  furnish  me  the  reference  of  publication. 

f  The  influence  of  this  latter  cause  of  multiple  calculi  was  happily  illustrated  in  a 
case  recently  brought  under  ray  notice  by  Dr.  Blake,  of  this  city,  of  an  old  lady  of  eighty, 
who  had  suffered  for  a  long  time  with  procidentia  of  the  uterus,  in  which  the  bladder 
was  also  involved.  On  repeated  occasions,  after  retention  of  urine  caused  by  their  ac- 
cumulation, she  had  discharged  quantities  of  minute  shot-like  phosphatic  calculi  through 
the  urethra,  and  after  death  the  bladder  contained  hundreds  of  these  little  rounded 
masses,  averaging  about  the  size  of  No.  6  shot. — Van  Bcren. 


CONSEQUENCES.  200 

When  their  number  is  small  they  influence  each  otlier's  shai)e,  and 
grow  to  be  many-sided  rather  than  round  or  ovoid,  the  obvious  result 
of  mutual  contact  or  friction,  giving  rise  to  flattened  sides  or  facets. 
When  a  stone  presenting  this  unusual  form  is  removed  by  lithotomy, 
it  suggests  at  once  the  probability  of  the  presence  of  others  in  the 
bladder.  If  very  numerous,  on  the  contrary,  and  apparently  Just  in 
proportion  to  their  number,  they  tend  to  revert  to  the  rounded  form. 

When  a  calculus  varies  from  the  common  ovoid  by  unusual  elonga- 
tion in  shape,  it  is  suggestive  of  the  presence  of  an  exceptional  nu- 
cleus— something  introduced  through  the  urethra.  In  calculi  of  this 
character  the  mass  is  ordinarily  friable,  being  composed  entirely  of 
phosphates.  At  the  same  time  this  friability  does  not  always  justify 
the  employment  of  lithotrity  as  a  'remedy,  for  the  nucleus  may  be  a 
substance  which  can  not  be  crushed,  as  in  some  of  the  instances 
already  mentioned,  and  notably  in  the  case  of  Henry  Thompson, 
where  a  stick  of  sealing-wax  was  found  in  the  center  of  the  mass,  a 
substance  which  at  the  temperature  of  the  body  is  quite  soft.* 

Vesical  calculi  present  great  variety  as  to  roughness  of  surface. 
Sometimes  as  smooth  as  a  well-worn  pebble,  they  are  generally  rough, 
from  crystalline  deposits,  and  these  asperities  are  in  some  cases  ex- 
ceedingly prominent  and  sharp.  In  very  rare  cases  calculi  assume 
fantastic  shapes  without  any  obvious  cause.  Occasionally  the  stone 
becomes  fixed  at  the  neck  of  the  bladder,  and  from  this  situation  it 
sends  forward  a  prolongation  into  the  prostatic  urethra  by  which  its 
shape  is  molded. 

In  regard  to  the  size  of  urinary  calculi,  very  little  more  of  practical 
value  can  be  said  here  that  does  not  come  more  properly  under  the 
heads  of  diagnosis,  and  selection  of  mode  of  cure.  Surgical  works  on 
this  subject  teem  with  rare  and  curious  cases  of  calculi  of  great  size 
and  weight,  the  largest  of  which  will  be  found  to  have  been  taken 
from  dead  bodies,  and  the  next  in  size  pretty  uniformly  to  have 
brought  about  fatal  results  by  their  removal  during  life.  It  will 
always  be  necessary  to  refer  to  old  authors  for  extravagant  examples 
of  this  kind,  for,  in  proportion  as  the  means  of  relief  which  surgery 
can  offer  become  more  safe  and  sure,  they  will  occur  more  rarely. 

Possible  Coxsequekces  of  Stoxe,  iis^cludixg  Symptoms  axd 
Pathology. — Uneasy  sensations,  referable  to  the  neck  of  the  bladder, 
desire  to  pass  water  recurring  with  unusual  frequency — both  due  to 
the  strange  impression  upon  the  nerves  of  the  organ,  and  generally 
ascribed  to  what  is  called  ''irritability" — are  the  first  evidences  of 

*  In  a  case  reported  by  Dr.  I.  Porter,  Jr.,  of  Massachusetts,  a  phosphatic  stone  three 
and  a  half  inches  in  length  by  one  and  three-quarters  inch  in  width,  and  weighing  three 
and  a  half  ounces,  was  taken  from  a  male  after  death.  It  was  found  to  hare  been  formed 
upon  a  stem  of  the  Archangdica  purpurea,  two  and  a  quarter  inches  in  length. — "  Boston 
Medical  and  Surgical  Journal,"  March  4,  1858. 


270  STONE   IX  THE  BLADDER. 

the  prcscnco  of  a  foreign  body  in  tlie  bltuldcr.  When  small  and 
movable,  as  it  nsnally  is,  the  foreign  body  is  liable  to  be  carried  by 
the  flow  of  nrine  to  the  outlet  of  the  bladder,  and  thus  to  cause 
sudden  stoppage  of  the  stream,  accompanied  by  a  twinge  of  sharp 
pain  shooting  along  the  course  of  the  urethra,  and  felt  most  acutely 
at  its  outlet.  The  muscles  at  the  neck  of  the  bladder  are  thrown  into 
spasmodic  contractions  by  the  presence  of  the  foreign  substance,  and 
grasp  it  closely  ;  if  its  surface  is  rough,  the  contact  brings  blood  from 
the  sensitive  and  vascular  membrane,  and  this,  when  the  spasm  re- 
laxes, is  voided  with  increased  difficulty  with  the  next  urine  that  flows. 
The  neck  of  the  bladder  is  its  most  sensitive  part,  and  the  recurrence 
of  this  rough  contact  sooner  or  later  begets  permanently  exaggerated 
sensibility,  together  with  increased  vascularity — in  other  Avords,  in- 
flammation. Inflammation,  under  these  circumstances,  always  begins 
at  the  neck  of  the  bladder,  and  indeed  may  be  for  a  long  time  confined 
to  this  locality  ;  but  it  tends,  sooner  or  later,  to  invade  the  body  of 
the  organ  ;  and  thus,  as  the  stone  grows  in  size,  after  a  longer  or 
shorter  period  of  simple  irritation,  cystitis  is  established— brought 
about  by  prolonged  repetition  of  mechanical  violence,  both  from 
contact  of  the  stone,  and  from  the  bruising  by  spasmodically  excited 
muscles  in  the  act  of  voiding  urine,  which  is  repeated  with  unnatural 
frequency  and  effort.  Inflammation  of  the  bladder  from  the  presence 
of  stone  is  always  gradual  in  its  approach,  and  chronic  in  its  char- 
acter. The  healthy  bladder  is  patient  under  violence,  and  slow  to 
take  on  true  inflammation,  so  that  cystitis  is  chronic  from  the  first ; 
and,  though  liable  to  acute  paroxysmal  exacerbations,  is  essentially 
chronic  in  its  manifestations  throughout.  During  the  first  weeks  or 
months  of  the  stone's  presence  in  the  bladder,  Avhile  as  yet  there  is  no 
cystitis,  but  irritation  only,  the  urine  remains  clear  and  bright,  show- 
ing only  a  slight  increase  of  mucus,  or  of  epithelial  debris,  and  occa- 
sionally a  little  blood.  The  blood  is  more  likely  to  be  present  after 
rough  or  violent  exercise,  or  a  jolting  ride.  But,  after  the  beginning 
of  cystitis,  pus-corpuscles  will  always  be  found,  generally  in  sufficient 
quantity  to  render  the  urine  turbid  to  the  eye,  and  always  recognizable 
bv  the  aid  of  a  microscope.  Meanwhile  the  muscular  coat  of  the 
bladder  is  taking  on  gradual  hypertrophy  from  increased  use,  and  its 
interlacing  fibers  begin  to  stand  out  in  relief ;  while  the  irritated 
organ,  intolerant  of  distention,  discharges  its  contents  at  still  shorter 
intervals,  and  thus  a  tendency  to  habitual  contraction  is  established. 
The  constant  presence  of  pus  in  the  urine  occasions  more  rapid  in- 
crease in  the  size  of  the  stone  from  phosphatic  precipitation,  and  the 
lining  membrane  of  the  bladder,  now  entirely  involved  in  chronic  in- 
flammation, loses  its  normal  tint  of  salmon  pink,  and  becomes  deep 
red,  granular,  or  perhaps  even  villous,  with  occasional  ecchymosis,  and 
sometimes  patches  of  yellowish  surface-exudation.     Most  of  the  exuda- 


SYMPTOMS.  271 

tion,  however,  takes  place  in  the  submucous  web  of  connective  tissue 
around  the  enlarged  follicles,  adding  materially  to  the  thickness  of  the 
bladder-walls. 

It  is  a  noticeable  feature  in  the  behavior  of  the  bladder  under  irri- 
tation, that  it  has  its  periods  of  excitement  and  quiescence  without  any 
obvious  cause,  the  inflammatory  phenomena  manifesting  themselves 
by  paroxysms  rather  than  by  steady  progress,  and  thus  Justifying  the 
old  expression,  ''a  fit  of  the  stone."  The  varying  conditions  of  the 
sexual  organs — so  closely  associated  with  the  bladder — may  throw 
some  light  on  this  peculiarity,  as  may  also  the  degree  of  nervous  im- 
pressibility of  the  sufferer  by  irritating  causes.  Be  this  as  it  may,  it 
is  certain  that  the  period  of  life  between  puberty  and  the  sixtieth 
year,  during  which  the  sexual  organs  are  active,  is  the  period  during 
which  stone  in  the  bladder  is  attended  by  the  greatest  amount  of 
suffering,  and  the  operations  required  for  its  relief  by  the  greatest 
danger. 

The  time  required  to  bring  about  the  changes  in  the  bladder  above 
described  varies  greatly.  A  child  may  carry  a  calculus  for  years,  and 
yet  the  urine  remain  bright  and  free  from  pus ;  in  an  adult,  months 
may  accomplish  extensive  alterations,  but  in  advanced  life,  where  the 
urinary  organs  are  especially  prone  to  take  on  morbid  changes,  and 
where,  indeed,  these  may  be  already  present  as  consequences  of  strict- 
ure or  enlarged  prostate,  it  is  fair  to  expect  the  most  serious  local  re- 
sults from  the  formation  of  stone.  Here  the  advantage  of  diminished 
sexual  excitability  and  increased  tolerance  is  counterbalanced  by  the 
lack  of  vigor  which  belongs  to  age. 

Pre-existing  lesions  of  the  obstructive  sort  in  an  old  man  may  have 
already  given  rise  to  chronic  cystitis,  with  contraction  of  the  bladder 
and  thickening  of  its  walls  ;  or,  as  occurs  not  uufrequently  from  pros- 
tatic obstruction,  the  bladder  may  have  given  ujd  the  struggle  to  over- 
come the  obstacle,  and  may  have  fallen  into  atony,  with  loss  of  con- 
tractile power  and  indefinite  expansibility.  The  pain  and  suffering  in 
the  first  of  these  two  conditions  are  infinitely  the  greater,  for  the 
spasmodic  contraction  of  the  hypertrophied  muscular  walls  of  the 
bladder  tends  to  grind  the  diseased  mucous  membrane  against  the 
newly-formed  stone,  often  to  force  the  stone  into  painful  contact  with 
the  more  sensitive  neck,  and  thus  add  to  the  existing  obstruction,  and 
increase  the  difficulty  and  frequency  with  which  the  urine  is  voided. 
In  the  latter  condition,  the  contractile  element  being  absent,  the  pa- 
tient is  compelled  to  draw  off  his  urine  with  a  catheter,  and  is  thus  free 
from  the  constantly  recurring  desire  to  urinate,  with  its  accompanying 
spasms  and  tenesmus,  and  suffers,  instead,  a  milder  pain  at  longer 
intervals.  It  is  worthy  of  notice  how  closely  the  muscular  element  in 
the  bladder  is  connected  with  the  pain  of  stone.  It  is  a  desideratum 
to  be  able  to  abolish  it  at  will.     At  present  we  can  accomplish  this  end 


272  STONE  IN  THE  BLADDER. 

only  temporarily  aud  imperfectly  by  opium,  and  (perhaps)  in  some 
degree  by  electricity. 

In  the  complicated  cases  of  vesical  calculus  which  we  are  now  con- 
sidering, other  changes  in  the  bladder  are  liable  to  take  place.  Of 
these  some  are  constant,  otlicrs  only  occasional.  Of  the  former,  the 
most  important  is  the  local  dilatation  at  its  base — a  sort  of  hollow  or 
scooping  out,  which  forms  immediately  behind  the  enlarged  prostate, 
called  by  the  French  the  ''bas-fond"  of  the  bladder.  This  becomes 
necessarily,  both  in  the  upright  and  horizontal  positions  of  the  body, 
the  deepest  as  well  as  the  most  deiDcndent  portion  of  the  cavity  of  the 
bladder,  and  it  is  therefore  usually  occupied  by  the  stone,  when  pres- 
ent ;  and  the  stone  is  thus,  in  a  measure,  prevented  from  contact  with 
the  sensitive  outlet  of  the  bladder.  The  excavation  of  the  bas-fond  is 
often  so  considerable  that  an  ordinary  sound  introduced  into  the  blad- 
der can  not  be  made  to  strike  a  calculus  lodged  here,  the  convexity  of 
the  instrument  passing  above  it,  and  failure  in  diagnosis  has  often  re-- 
suited  from  this  cause.  A  sound  with  a  short  curve,  like  that  of  a 
lithotrite,  so  that  its  beak  can  be  reversed  in  the  cavity  of  the  bladder 
and  swept  across  its  base,  is  the  instrument  to  be  employed  whenever 
the  presence  of  stone  is  suspected  in  conjunction  with  an  enlarged 
prostate.  Calculi  may,  and  often  do,  form  in  the  little  pouches  Jut- 
ting out  between  the  meshes  of  hypertrophied  muscular  fibers  known 
as  sacculi,  and  sometimes  become  so  large  as  to  be  permanently  en- 
trapped in  their  cavities. 

In  the  cases,  and  they  are  not  infrequent,  in  which  the  bladder  has 
lost  its  contractile  power,  unless  the  catheter  be  employed  at  regular 
intervals,  the  bladder  is  constantly  in  an  overstretched,  water-logged 
condition,  relieving  itself,  irregularly  and  imperfectly,  by  si^ontaneous 
overflow.  Civiale  calls  this  '^ stagnation."  Under  these  circum- 
stances, and,  indeed,  whenever  the  outlet  of  the  bladder  is  the  seat  of 
obstruction,  the  ureters,  subjected  also  to  overdistention,  become 
dilated  and  tortuous  ;  the  inflammation  of  the  mucous  membrane  of 
the  bladder  extends  to  and  gradually  involves  their  altered  and  weak- 
ened walls,  and,  continuing  to  extend,  finally  invades  the  pelves  of  the 
kidneys.  The  secreting  structure  of  the  kidneys,  predisposed  to  dis- 
ease by  disturbance  of  functions,  now  soon  participates  in  the  advanc- 
ing disorder,  and  functional  disturbance  of  serious  import,  attended 
by  evidences  of  uremic  poisoning,  foreshadows  the  fatal  result  which 
is  imminent.  This  is,  j)robably,  the  most  usual  course  by  which  the 
end  of  life  is  reached  in  vesical  calculus  not  interfered  with  by  art, 
especially  when  associated  with  obstructive  disease,  i.  e.,  stricture  or 
enlarged  prostate.  Ulceration  of  the  chronically  inflamed  mucous 
membrane  of  the  bladder  occurs  in  a  small  proportion  of  cases.  A  few 
instances  arc  on  record  in  which  calculi  have  worked  their  way  out  of 
the  bladder  through  ulcerations  involving  all  of  its  coats,  and  have 


SYMPTOMS.  273 

boon  ultimately  found  in  the  vagina,  the  pcrina3um,  the  umbilicus,  and 
even  in  the  groin.  Urinary  exti'avasation  does  not  seem  to  have  oc- 
curred in  these  cases,  the  whole  process  being  apparently  conservative, 
an  effort  on  the  part  of  Nature  to  get  rid  of  the  foreign  body.  Proba- 
bly abscess  in  the  thickened  walls  of  the  bladder,  opening  inward,  first 
receives  the  calculus,  which  travels  as  the  abscess  burrows  in  search  of 
an  outlet.  These  conservative  efforts  of  Nature  are  always  of  great 
interest  to  the  surgeon,  as  they  not  only  justify,  but  suggest  the  efforts 
of  art  in  search  of  modes  of  cure.  When  death  has  occurred  from 
stone,  numerous  small  abscesses  are  often  found  in  the  thickened  and 
altered  walls  of  the  bladder,  and  also  in  the  substance  of  the  kidneys. 
Multiple  abscesses  not  unfrequently  form  in  the  enlarged  prostate, 
and  instances  are  not  very  rare  in  which  the  whole  prostate  has  broken 
down  into  an  abscess.  Abscess  outside  of  the  bladder,  in  the  neigh- 
borhood of  its  neck,  from  pericystitis,  and  pelvic  cellulitis  terminat- 
ing in  abscess,  are  complications  of  possible  occurrence ;  and  in  chil- 
dren, where  the  peritonseum  covers  so  much  larger  a  proportion  of  the 
bladder-base  than  in  the  adult,  both  acute  and  chronic  peritonitis  have 
been  encountered,  not  only  caused  by  stone,  but  produced  by  opera- 
tions for  its  relief,  both  by  the  knife  and  the  lithotrite. 

Symptoms  consideeed  in  Eelatiok  to  Diagnosis  and  Selec- 
tion OF  Mode  of  Cure. — The  symptoms  of  stone  in  the  bladder  are 
pain,  increased  frequency  of  the  desire  to  void  urine,  difficulty  in  the 
act  of  micturition,  occasional  presence  of  blood  in  the  urine. 

Pain. — As  to  the  pain  caused  by  stone,  it  is  uncertain,  variable, 
and  capricious.  Sometimes  entirely  wanting,  it  is  not  unfrequently 
constant  and  agonizing.  In  a  majority  of  cases  its  principal  seat  is 
the  neck  of  the  bladder,  extending  along  the  course  of  the  urethra  ; 
but  it  often  will  happen  that  a  patient,  when  asked  to  fix  the  point  of 
his  greatest  suffering,  will  indicate  the  under  surface  of  the  glans 
penis,  just  behind  the  frasnum.  This  explains  the  tendency  of  most 
calculous  patients  of  the  male  sex  to  habitually  squeeze  and  rub  this 
part,  as  this  sort  of  manipulation  seems  evidently  to  dull  the  edge  of 
extreme  pain.  Unhappily,  young  subjects  are  thus  prone  to  acquire 
the  habit  of  self-abuse.  Children  with  stone  habitually  pull  upon  the 
prepuce,  and  its  unnatural  elongation  is  usually  regarded  as  one  of  the 
signs  of  the  disease.  The  rectum  is  a  common  seat  of  uneasy  sensa- 
tion, if  not  of  acute  pain  ;  this  is  especially  noticeable  in  prostatic 
cases,  where  there  is  a  das-fond,  for  here  the  stone  lies  almost  in  con- 
tact with  the  walls  of  the  lower  bowel.  When  the  bladder  has  become 
inflamed  and  altered,  more  or  less  dull  pain  is  felt  above  the  pubes, 
radiating  to  the  hips,  sacrum,  thighs,  and  perinseum.  The  pain  in 
vesical  calculus  is  aggravated  by  motion,  whether  active  or  passive, 
and  it  is  relieved  by  quiet  and  rest ;  especially  by  rest  on  the  back  with 
the  hips  raised.  But  the  greatest  pain  of  stone  is  usually  felt  in  the  act 
18 


274  STONE   IN   THE  BLADDER. 

of  passing  water,  and  mainly  toward  the  close  of  the  act,  when  the  blad- 
der, empty  of  urine,  grasps  the  stone  with  violence,  and  forces  it 
against  the  sensitive  orifice  of  the  urethra,  as  if  determined  to  eject  it. 
Often  a  veritable  spasm  seems,  in  this  crisis,  to  seize  all  the  muscular 
tissues  in  the  neighborhood  of  the  outlet  of  the  bladder.  "While  suf- 
fering from  this  pain,  the  child,  unrestrained  by  modesty,  and  giving 
full  vent  to  his  feelings,  will  grasp  his  genitals  and  dance  around  the 
room,  howling  with  anguish. 

In  estimating  the  value  and  significance  of  pain  as  a  symptom  of 
stone,  it  must  be  borne  in  mind  that  jiain  of  a  similar  kind,  although 
less  in  degree,  is  also  present  in  cystitis  of  the  neck  of  the  bladder, 
from  any  cause,  and  also  in  simple  nervous  irritability  of  the  neck  of 
the  bladder  from  sexual  causes — "neuralgia  of  the  vesical  neck" — au 
affection  too  often  ignored.  In  this  latter  condition  the  pain  and  fre- 
quency of  voiding  urine  are  sometimes  greater  than  in  actual  inllam- 
mation.  The  sensibility  to  pain,  or  impressionability  of  the  sufferer, 
is  also  to  be  taken  into  account,  and,  above  all,  the  condition  of  the 
genital  organs,  as  to  healthy  innervation  ;  for,  unsatisfied  sexual  long- 
ings, and  unnatural  practices  employed  to  gratify  these  longings,  beget 
a  peculiar  hyperajsthesia  of  the  genitals,  in  which  the  urinary  organs 
largely  share. 

3IispJaced  sensations  are  sometimes  caused  by  the  chronic  inflam- 
mation due  to  stone  or  other  cause,  the  more  common  expressions  of 
pain  being  absent,  as  in  Brodie's  case,  where  a  long-existing  neuralgia 
of  the  foot  was  relieved  by  the  discovery  and  cure  of  an  old  stricture 
of  the  urethra.*  Nor,  finally,  must  it  be  forgotten  that  stones  have 
been  found  in  the  bladder  after  death  in  persons  who  had  given  no 
evidence  of  the  existence  of  the  disease  during  life. 

Increased  frequency  of  desire  to  void  uj'ine  is  also  a  symptom  of 
the  diseases  of  the  neck  of  the  bladder  just  enumerated,  as  well  as  of 
stone,  and  the  pain  in  the  act  is  also,  as  a  rule,  greatest  at  its  close, 
just  as  the  tender  parts  are  grasped  spasmodically  by  the  extending 
muscles.  But  in  stone  this  final  spasmodic  pain  is  infinitely  more 
acute,  it  lasts  longer,  and  seems  to  be  more  apt  to  be  mitigated  by 
pressure  at  the  head  of  the  penis. 

The  presence  of  a  little  blood  in  the  urine  in  conjunction  with  pain 
at  the  close  of  the  act,  especially  after  active  exercise  or  riding  over  a 
rough  road,  is  very  significant  of  stone  ;  but  this  conjunction  of  symp- 
toms is  also  occasionall}'  present  in  other  bladder,  urethral,  and  kidney 
diseases.     {See  H^matukia.) 

Perhaps  the  most  characteristic  symptom  of  stone  is  the  sudden 
arrest  of  the  stream  of  urine  while  in  full  flow,  accompanied  by  simul- 
taneous spasmodic  contractions  of  the  muscles  at  the  neck  of  the  blad- 

*  Sec  an  excellent  article,  "  Pododynia,"  J.  B.  Curtis,  "  Boston  Medical  and  Surgical 
Journal,"  April  7,  1881,  p.  316. 


SYMPTOMS.  275 

der,  with  coincident  sharp  and  severe  pain.  This  group  of  symptoms 
is  produced  by  the  falling  of  a  movable  body  in  tiic  Ijladder,  over  the 
orifice  of  the  urethra,  so  as  to  close  it  suddenly  as  by  a  ball-valve.  In 
the  rare  case  of  a  polypus,  or  of  a  prostatic  tumor  growing  from  within 
the  neck,  the  tumor  in  either  case  being  attached  by  a  slender  pedicle, 
the  same  phenomenon  has  been  known  to  occur.* 

It  will  thus  be  seen  that,  of  the  cardinal  symjotoms  of  stone,  there 
is  no  one  that  is  absolutely  pathognomonic  of  the  disease,  and  that 
clinical  study  and  experience  are  necessary  to  the  proper  estimate  of 
their  significance.  Study  of  the  patient's  habits,  history,  constitution, 
and  hereditary  tendencies,  will  materially  aid  in  forming  a  judgment 
as  to  probabilities.  The  same  symptoms  would  possess  a  very  different 
value  before  puberty  and  after  the  age  of  forty  ;  for,  in  childhood,  all 
the  diseases  mentioned  above  as  likely  to  be  confounded  with  stone 
could  be  at  once  excluded,  and  the  irritation  caused  by  excessive  acidity 
alone  would  remain  to  be  considered. 

In  estimating  the  pathological  condition  of  the  urinary  passages  as 
affected  by  the  presence  of  calculus,  the  microscopical  and  chemical 
examination  of  the  urine  must  not  be  neglected.  The  existence  of 
true  inflammation  can  always,  by  this  means,  be  distinguished  from 
simple  irritation  by  recognizing  the  presence  of  pus-globules  in  any 
quantity ;  and  the  character  of  these  globules  would  seem  to  furnish 
some  evidence  as  to  whether  they  are  the  result  of  mere  surface  irrita- 
tion, or  of  deeper  and  more  serious  lesions  of  tissue,  f  Pus  in  the 
urine  may  come  from  the  secreting  structure  of  the  kidney,  as  when  it 
assumes  the  form  of  tubular  casts ;  from  the  pelvis  of  the  kidney ; 
from  the  ureters,  bladder,  or  urethra  ;  and,  except  in  the  case  of  casts, 
its  source  is  to  be  distinguished  mainly  by  the  coexisting  evidences  of 

*  Willis  deposited  in  the  Museum  of  the  Royal  College  of  Surgeons,  London,  a  bladder 
taken  from  a  man  of  sixty-seven,  dead  of  cancer  of  the  kidney,  in  which  there  was  "  a 
small  polypoid  body  growing  from  its  inner  surface,  directly  over  the  orifice  of  the  urethra, 
and  covered  by  a  shell  or  crust  of  the  triple  phosphate.  ...  He  had  long  suffered  from 
occasional  attacks  of  retention  of  urine  and  symptoms  of  stone.  .  .  .  Retention  of  urine 
was  the  urgent  symptom  of  the  case."  It  was  always  relieved  by  the  introduction  of  a 
small  flexible  bougie,  alongside  of  which  the  urine  would  escape.  The  bougie  evidently 
pushed  away  the  ball-valve,  and  was  substituted  for  the  catheter,  as  it  answered  the  same 
purpose,  with  less  irritation. — "  Urinary  Diseases  and  their  Treatment,"  by  Robert  Willis, 
M.  D.,  London,  1838,  p.  284. 

\  "  Quite  normal  pus-corpuscles  of  a  perfectly  circular  outline,  which,  after  treatment 
with  acetic  acid,  exliibit  the  characteristic  nucleus,  composed  mostly  of  two  or  three 
nucleoli,  admit  of  the  conclusion  that  the  disease  giving  rise  to  their  formation  is  of  a 
mild  form — a  simple  catarrh  of  the  mucous  membrane.  But  when  the  pus-corpuscles  are 
irregular  in  form  and  outline,  and  on  treatment  with  acetic  acid  show  an  irregular  nucleus, 
or  an  indistinct  granular  mass  in  their  interior,  or  when  such  corpuscles  are  mixed  with 
irregular  debris,  not  particularly  defined,  then  purulent  destruction  is  evident,  and  the 
integrity  of  the  organ  where  this  formation  takes  place  is  in  great  danger,  or  lost  alto- 
gether. Such  pus  would  be  the  product  of  ulceration  and  tuberculosis." — Vogel,  quoted 
by  Thudichura,  "Pathology  of  the  Urine,"  London,  1858,  p.  259. 


276  STONE   IX   TUE   BLADDER. 

local  lesions.  In  pus  from  the  pelves  of  the  kidneys  the  globules  are 
free  and  not  collected  in  masses,  and  the  whole  deposit  is  heavy,  sink- 
ing rapidly  to  the  bottom  of  the  vessel,  and  often  presenting  to  the 
naked  eye  a  peculiar  greasy  ai^pearance.  Pain  on  pressure  over  the 
site  of  the  kidney,  or  the  presence  of  any  unusual  swelling  or  tumor 
in  this  locality.  Avill  aid  in  recognizing  ]>yelitis,  which  is  almost  invari- 
ably accompanied  by  more  or  less  hectic  and  emaciation.  Pus  from 
the  urethra  is  apt  to  assume  the  shape  of  floating  thread-like  filaments 
visible  to  the  naked  eye.  .These  are  washed  from  the  surface  of  the 
urethra  by  the  passing  urine,  rolled  over  and  over,  and  thus  spun  into 
threads.  Moreover,  pus  from  tlie  bladder  can  alwa^'s  be  distinguished 
from  that  furnished  by  the  urethra  by  collecting  the  urine  which  passes 
first  and  contains  the  washings  of  the  urethra  in  a  separate  vessel,  and 
comparing  it  with  that  which  comes  afterward. 

A  very  common  error  in  practice  is  to  mistake  the  gelatinous  mucoid 
material  wliich  results  from  the  reaction  in  the  bladder  of  ammonia 
upon  pus  for  true  mucus,  and  thus  fail  to  recognize  the  existence  of 
cystitis,  perhaps  already  well  established  and  extensive.  Tlie  student 
of  urinary  diseases  who  will  take  the  trouble  to  agitate  in  a  test-tube  a 
drachm  of  pure  pus  derived  from  any  source  with  an  equal  quantity  of 
aqua  ammonige,  and  observe  the  result,  will  hardly  fall  into  this  error. 
True  mucus,  which  is  always  present  in  healthy  urine,  collecting  in  a 
floating  cloud  of  variable  density  as  the  urine  cools,  is  furnished  by  the 
mucous  follicles,  which  everywhere  line  the  urinary  passages.  That 
furnished  by  the  urethra  is  notably  increased  by  erotic  excitement. 
Mucus  from  the  urinary  passages  proper  is  liable  to  be  temporarily  in- 
creased by  greater  density  or  more  irritating  quality  of  the  urine  ;  thus, 
the  morning  urine  will  always  show  a  larger  cloud  of  mucus.  The 
presence  of  a  foreign  body  in  the  bladder  notably  increases  the  amount 
of  mucus  in  the  urine.  Pure  mucus  is  always  translucent,  and  its 
diagnosis  may  be  established  by  the  number  of  epithelial  cells  imbedded 
in  its  substance.  The  mucus-corpuscle  can  not  be  distinguished,  singly, 
from  the  pus-corpuscle,  and  perhaps  neither  of  them  from  a  young 
epithelial  cell ;  but,  in  mass,  the  difficulty  ceases.  The  amount  of 
mucus  present  in  urine  is  rarely  sufficiently  large  to  lead  to  its  being 
mistaken  for  gelatinoid  pus.  "When  there  is  any  doubt,  the  habitual 
presence,  in  any  considerable  quantity,  of  pus-globules  will  readily 
settle  the  question  in  favor  of  the  latter  ;  gelatinous  pus  in  any  quan- 
tity, moreover,  is  never  found,  except  when  the  urine  is  alkaline.  It 
is  generally  associated,  therefore,  with  the  earthy  phosphates  ;  and, 
when  the  prismatic  crystals  of  the  triple  phosphate  of  ammonia  and 
magnesia  are  found  imbedded  in  it,  the  presence  of  ammonia,  arising 
most  probably  from  decomposition  of  urea,  may  be  safely  assumed. 
Finally,  in  cases  where  mucoid  pus  is  largely  present,  the  daily  wash- 
ing out  of  the  bladder  with  tepid  water  will  often  restore  the  normal 


SOUNDING. 


277 


A 


acidity  of  the  urine,  by  removing  the  ammonia  and  otlior  irritating 
causes,  and,  simultaneously  with  this  change,  the  mucoid  pus  will  dis- 
appear, to  be  replaced  by  a  deposit  of  ordinary  pus,  usually  diminished 
in  quantity  by  the  soothing  influence  of  the  fomentation.  Attention 
to  these  facts  will  tend,  in  obscure  cases,  to  facilitate  the  diagnosis  of 
stone.  The  presence  of  the  symptoms  of  vesical  calculus  which  have 
been  detailed,  or  of  any  of  them,  when  their  cause  can  not  be  clearly 
made  out  after  mature  consideration,  justifies  a  formal  exploration  of 
the  interior  of  the  bladder  by  means  of  a  sound.  Such 
further  examination,  it  should  rather  be  said,  becomes  a 
duty  ;  for  the  paramount  importance  to  the  patient  of  the 
early  discovery  of  a  stone  in  his  bladder,  in  view  simply  of 
the  comparative  safety  with  which  he  can  be  relieved  of  a 
small  stone  before  its  presence  has  caused  morbid  change 
in  the  bladder,  renders  an  early  resort  to  the  only  certain 
test  of  its  presence  an  imperative  obligation  upon 
his  surgeon. 

Sounding. — The  operation  of  sounding  a  pa- 
tient for  stone  requires  a  light  hand  and  gentle 
manipulation.  It  should  not  be  resorted  to  dur- 
ing a  "fit  of  the  stone";  nor,  if  there  be  any 
suspicion  of  cancer  of  the  bladder,  without  great 
circumspection,  for  severe  hgeniorrhage  and  aggra- 
vation of  symptoms  have  followed,  in  such  event. 
Previous  preparation  is  advisable  in  persons  who 
suffer  much,  by  rest,  diluents,  alkalies,  if  indi- 
cated, or  possibly  anodynes.  In  all  serious  cases 
a  period  of  comparative  quiescence  of  the  symp- 
toms should  be  chosen  for  the  operation.  An 
anaesthetic  is  required  for  adults  only  exception- 
ally ;  for  children  it  is  desirable  in  the  large  ma- 
jority of  cases  ;  and,  as  a  matter  of  complaisance, 
perhaps,  for  women.  The  instrument  should  be 
of  metal,  with  a  short  curve,  like  that  of  a  litho- 
trite,  and  slightly  bulbous  at  its  beak.  The 
"searcher"  of  Sir  Henry  Thompson  (Fig.  76), 
the  best  sound  in  use  at  present,  is  capable  of 
serving  a  double  purijose ;  for  it  is  hollow  like  a 
catheter,  with  an  eye  near  its  beak,  and  a  metal 
I)lug  fitted  to  its  open  end,  so  that  the  urine  in  the  bladder  can  be 
drawn  off,  if  in  excess,  or  warm  water  injected,  if  necessary,  during 
the  operation.  Mercier's  "sonde  coud6e"  has  a  different  curve,  and, 
although  not  a  catheter,  is  an  excellent  searcher  (Fig.  77).  The 
patient  should  lie  on  his  back,  with  his  hips  slightly  raised,  on  a 
firm  bed  or  lounge,  so  placed  that  the  operator  may  act  from  his 


Fig.  77 


Fig.  76. 


278  STONE   IN   TUE   BLADDER. 

right  side,  for  the  sound  is  preferably  iutroduced  from  this  side,  in 
order  that  the  operator  shall  be  in  position  to  use  his  right  hand  most 
advantageously,  and  without  changing  sides  when  the  sound  shall 
have  entered  the  bladder.  The  manipulation  emiiloyed  in  intro- 
ducing the  sound  is  the  same,  with  trifling  moditication,  as  that  re- 
quired for  the  lithotrite  (Chapter  XVI).  When  in  the  bladder,  the 
sound  is  to  be  pushed  gently  onward,  until  the  posterior  wall  of  the 
bladder  is  reached,  when,  withdrawing  it  sliglitly,  its  beak  is  to  be 
turned  carefully,  first  to  one  side  and  then  to  the  other,  until  the 
lateral  wall  or  floor  of  the  bladder  is  touched,  by  rotating  its  shaft 
between  the  thumb  and  finger  ;  then  it  is  withdrawn  an  inch — more  or 
less — and  the  same  manoeuvre  repeated  ;  this  is  done  again  and  again, 
if  necessary,  until  the  concavity  of  the  sound  comes  in  contact  with 
the  neck  of  the  bladder,  when  it  is  withdrawn  entirely.  For  a  patient 
under  middle  age,  this  mode  of  examining  with  the  sound  Avould  be 
adequate  to  the  discovery  of  a  calculus,  if  present,  in  a  large  majority 
of  cases.  Nevertheless,  it  is  a  safe  rule  of  practice,  never  to  decide 
the  question  after  a  first  examination  in  which  the  result  has  been 
negative,  but  to  ask  for  a  second  or  even  a  third  opportunity  for  search, 
before  giving  a  positive  opinion;  and  not  to  lose  sight  of  the  great 
advantages  to  be  derived  from  ether  or  chloroform.*  But,  in  a  male 
patient  over  the  age  of  forty,  there  is  always  a  possibility  that  the 
bladder  may  have  undergone  a  change  in  shape  at  its  base — such  as 
has  been  already  described  as  forming  a  pouch  behind  the  enlarged 
prostate — and  here  another  manoeuvre  of  great  jiractical  value  is  to 
be  added  to  the  operation.  Instead  of  Avithdrawing  the  sound  entirely, 
when  its  concavity  has  reached  the  neck  of  the  bladder,  as  first  directed, 
its  beak  is  to  be  again  carried  forward  to  the  center  of  the  bladder, 
and,  the  handle  of  the  instrument  being  well  depressed  between  the 
thighs,  its  beak  is  to  be  rotated  by  a  complete  half-turn  of  the  shaft, 
so  as  to  assume  a  reversed  position  and  touch  the  floor  of  the  bladder ; 
keeping  the  handle  of  the  sound  sufficiently  depressed  to  render  its 

*  Early  in  1847  a  boy  of  two  and  a  half  years  was  brought  to  me,  with  a  history  of 
great  sufferinji,  as  from  stone,  since  shortly  after  birth,  but,  althoudi  examined  half  a 
dozen  times,  none  had  been  discovered.  The  little  fellow  strugjrled  violently,  and  he  was 
necessarily  held  by  main  force.  As  soon  as  the  sound  entered  it,  hi.s  bladder  was  seized 
by  spasm  and  its  contents  forcibly  discharged,  and  simultaneously  the  contents  of  the 
rectum  also.  The  sound  was  so  firmly  grasped  by  the  empty  bladder  that  its  beak  could 
not  be  moved  without  force,  and  with  great  increase  of  outcry.  Under  these  circum- 
stances I  bethought  me  of  the  new  remedy  which  I  had  seen  used  a  short  time  before  by 
Morton,  upon  a  patient  of  the  late  Valentine  Mott,  and  brought  it  to  bear  upon  my 
refractory  patient.  The  result — with  which  we  arc  now  so  familiar  from  daily  use — was 
then  novel,  and  it  was  wonderfully  satisfactory.  A  small  movable  stone  was  struck  by 
the  sound  almost  as  soon  as  it  entered  the  relaxed  and  insensible  bladder.  A  week  latci- 
it  was  removed  by  the  lateral  operation,  under  ether,  and  a  prompt  recovery  followed. 
The  patient  subsequently  served  creditably  during  the  late  war.  I  believe  this  to  have 
been  the  first  case  of  lithotomy  with  anaesthesia. — Van  Buren. 


CHOICE  OF  METHOD  OF  CURE.  279 

beak  readily  movable,  this  is  now  to  bo  gently  swept  from  side  to  side, 
as  when  it  occupied  the  first  position,  and  it  will  pretty  certainly  strike 
a  calculus,  if  any  be  present,  in  a  pouched  has-fond  behind  an  enlarged 
prostate.  Tlic  beak  of  the  sound  is  then  to  be  carried  again  to  the 
center  of  the  bladder,  with  its  handle  still  depressed,  and  restored  to 
its  first  position  by  a  half-rotation  of  the  shaft  of  the  instrument,  and 
then  carefully  withdrawn.  The  whole  operation  should  never  exceed 
three  minutes.  When  performed  with  due  gentleness,  it  should  cause 
but  little  pain,  unless  the  patient  is  unusually  sensitive,  or  the  bladder 
in  a  state  of  acute  inflammation.  In  the  latter  case,  if  delay  be  not 
admissible,  the  propriety  of  anaesthesia  should  be  considered  ;  for  the 
condition  of  painlessness  affords  the  operator  undeniable  advantages 
in  attaining  his  object,  although,  with  an  unpracticed  hand,  it  possi- 
bly increases  his  liability  to  do  harm. 

It  is  desirable  that  there  should  be  from  three  to  six  ounces  of  urine 
in  the  bladder  when  the  sound  is  used^  or,  in  other  words,  that  the 
patient  shall  have  retained  his  water  from  an  hour  and  a  half  to  three 
hours.  If  too  full,  a  small  stone  is  more  likely  to  escape  recognition  ; 
if  the  bladder  contains  less  than  three  ounces,  the  sound  is  less  easily 
manageable  without  rough  contact  with  its  walls.  It  happens  some- 
times, on  the  first  contact  of  the  beak  of  the  sound  with  the  walls  of  a 
sensitive  bladder,  that  the  organ  is  thrown  into  a  state  of  spasm,  and 
the  urine  forced  out  through  the  urethra,  alongside  of  the  shaft  of  the 
sound.  "When  this  accident  occurs,  it  is  better  to  defer  the  operation  ; 
or  administer  an  anaesthetic,  and,  reintroducing  the  sound,  inject 
througli  it  four  ounces  of  blood- warm  water,  and  then  jiroceed  with  the 
exploration. 

If  a  calculus  be  struck  shortly  after  the  sound  has  entered  the  blad- 
der, the  operator  has  then  a  chance  of  forming  at  once  some  idea  also 
of  the  condition  of  its  walls,  and  of  the  size,  roughness,  and  degree  of 
hardness  of  the  stone  ;  for  the  sharp  click  of  a  hard  stone  is  not  difiicult 
to  distinguish  from  the  muffled  sensation  received  from  a  soft  one,  and, 
if  the  beak  of  the  sound  in  contact  with  the  stone  is  made  to  glide  along- 
side of  it  by  slow  advance  or  withdrawal,  a  pretty  accurate  idea  of  its 
size,  and  of  the  degree  of  roughness  of  its  surface,  may  be  acquired. 

After  the  operation  of  sounding,  it  is  safer  that  the  patient  should 
have  warmth  applied  to  the  hypogastrium  and  to  the  feet,  and  that  he 
should  keep  his  bed,  at  least  for  the  remainder  of  the  day  ;  in  short,  he 
should  be  treated  as  after  the  use  of  the  lithotrite. 

Choice  of  Method  of  Cure. — When  the  presence  of  a  stone  in  the 
bladder  has  been  demonstrated,  the  questions  at  once  present  them- 
selves :  Can  the  patient  be  cured  by  the  crushing  operation  ?  must  he 
submit  to  lithotomy  ?  or,  is  it  more  judicious  to  employ  no  surgical 
operation  in  the  case,  but  simply  to  palliate  symptoms  by  such  medical 
treatment  as  may  relieve  from  pain  and  prolong  life  ? 


280  STONE  IN  THE  BLADDER 

It  may  be  safely  assumed,  in  general  terms,  that  a  cure  by  operation 
may  be  undertaken  in  any  case  of  stone  in  which  the  patient  is  not  of 
extreme  age,  where  the  stone  is  not  of  unusual  magnitude,  and  where  the 
patient  is  free  from  evidence  of  any  organic  disease  by  which  life  is 
likely  to  be  "terminated  within  a  limited  period  not  very  far  distant. 
But  we  are  compelled  by  the  requirements  of  practice  to  reduce  these 
questions  to  a  narrower  limit.  Cases  are  constantly  presenting  them- 
selves in  which  the  patient's  age  is  not  extreme,  and  his  general  health 
sufficiently  vigorous,  but  his  stone  so  large  that  it  can  be  removed  only 
with  the  aid  of  the  knife — by  an  operation  the  mortality  of  which 
modern  science  has  not  been  able  greatly  to  reduce.  Here  the  judg- 
ment of  the  surgeon  is  to  be  guided  by  the  following  considerations  : 
the  degree  of  the  patient's  suliVrings,  the  probable  amount  of  relief  to 
be  exijccted  from  palliative  measures,  and  the  temper  and  circumstances 
of  the  patient,  as  measuring  his  probable  capacity  to  properly  care  for 
himself,  and  command  the  comforts  of  an  invalid.  In  the  case  of  an  old 
man  able  to  command  all  the  comforts  of  life,  with  a  large  stone,  suf- 
fering only  moderately,  and  able  still  further  to  lessen  existing  suffering 
by  skillful  care,  it  would  be  obviously  the  part  of  wisdom  and  humanity 
to  hesitate  in  advising  an  operation.  The  simple  fact  that  an  operation 
can  be  done  is  no  reason  why  it  should  be  done  in  the  face  of  very 
serious  risk  to  life  ;  and  it  is  hardly  necessary  to  say  that  the  temptation 
to  perform  a  capital  operation,  even  at  his  urgent  request,  should  never 
weigli  for  a  moment  against  the  best  interests  of  the  patient  who  places 
his  life  in  our  hands.  The  considerations  Avhich  influenced  Franklin 
and  D'Alembert  to  decline  lithotomy  at  the  hands  of  Desault,  at 
Paris,  in  1784,  still  hold  good,  for  the  mortality  of  this  operation  has 
not  diminished  since  the  da^^s  of  Cheselden. 

Having  determined,  then,  that  it  is  proper,  in  certain  cases,  to 
decline  an  operation  for  stone,  Avhat  course  should  be  adopted  after  an 
examination  has  ascertained  the  presence  in  the  bladder  of  a  movable 
calculus  of  moderate  dimensions  ?  The  amount  of  inconvenience 
caused  by  the  operation  of  sounding  should  be  observed,  as  indicating, 
in  a  general  way,  the  condition  of  the  bladder,  and  the  measure  of  the 
patient's  tolerance  ;  and  further  exploration  should  be  deferred  until  all 
increased  trouble  that  may  have  been  caused  by  it  shall  have  subsided. 
Meanwhile  the  patient's  history  and  present  general  condition  should 
be  carefully  studied,  and  the  vital  organs  subjected  to  physical  explora- 
tion. Especial  attention  should  be  devoted  to  the  kidneys  and  bladder, 
both  by  physical  exploration,  externally  from  the  abdomen,  the  loins, 
and  rectum,  to  detect  tenderness  on  ju-essure,  or  tumor,  and  also  by 
careful  and  repeated  microscopical  and  chemical  examinations  of  the 
urine.  Much  information  will  thus  be  obtained  as  to  the  condition 
of  the  bladder,  the  constitution  of  the  urine,  and  an  accurate  idea  of 
the  size  and  state  of  the  prostate.     AVhen  the  proper   interval  has 


CHOICE   OF   METHOD   OF  CURE.  281 

elapsed,  a  full-sized  sound  or  bougie  is  to  be  introduced  tljrough  the 
urethra  for  the  purpose  of  testing  the  temper  and  capacity  of  this  canal, 
and  to  detect  the  existence  of  stricture,  if  present.  If  the  patient  be 
sensitive,  this  may  be  relocated  several  times,  at  proper  intervals,  as  it 
serves  to  diminish  abnormal  irritability  of  the  urethra,  often  present 
from  habitual  contact  of  altered  urine  ;  to  educate  the  passage,  as  it 
were,  to  tolerance  of  instruments  ;  to  familiarize  the  patient  to  his  sur- 
geon ;  and  to  lessen  the  nervous  dread,  which  always  exists  in  some 
degree,  of  his  manipulations.  If  the  urethra  has  been  proved,  to  be 
healthy,  and  of  normal  capacity ;  if  the  patient  can  retain  his  urine 
from  one  and  a  half  to  two  hours,  and  is  in  fair  general  condition,  the 
introduction  of  a  lithotrite  may  be  undertaken.  Its  object  is  to  seize  and 
measure  the  exact  size  of  the  stone  ;  to  ascertain,  while  the  stone  is  in 
the  grasp  of  the  lithotrite,  if  there  be  any  other  stones  present  in  the  blad- 
der (for  it  is  only  by  this  manoeuvre  that  the  presence  of  other  calculi  can 
be  certainly  demonstrated);  to  recognize  any  abnormal  condition  of  the 
internal  surface  of  the  bladder,  such  as  undue  prominence  of  its  muscu- 
lar fasciculi,  or  possibly  the  existence  of  sacculi ;  and  to  determine  with 
more  accuracy  the  degree  of  tolerance  of  the  organ,  in  view  of  the  fea- 
sibility of  lithotrity.  An  instrument  of  moderate  size,  and  with  per- 
fectly smooth  blades,  should  be  selected  for  this  operation,  and  it  should 
be  introduced  and  managed,  while  in  the  bladder,  in  the  manner  here- 
after described.  The  lithotrite  should  not  be  kept  in  the  bladder 
longer  than  three  minutes.  If  this  exploration  is  satisfactorily  accom- 
plished, if  the  stone  does  not  measure  more  than  one  and  a  half  to  two 
inches  in  diameter,  is  solitary,  and  the  bladder  has  proved  tolerant  of 
the  presence  of  the  instrument  and  of  the  whole  proceeding,  it  may 
be  safely  concluded  that  the  case  is  a  proper  one  for  the  crushing 
operation. 

Thus  far  the  patient  has  been  assumed  to  present  conditions  en- 
tirely favorable  to  lithotrity,  viz.,  good  general  health,  a  tolerant  blad- 
der, a  urethra  of  normal  capacity,  and  a  moderately  soft  stone,  not 
more  than  an  inch  in  diameter.  But  cases  of  this  kind  constitute  but 
a  small  percentage  of  the  aggregate  encountered  in  practice.  It  is  neces- 
sary that  the  surgeon  should  have  an  accurate  perception  of  all  the 
conditions  that  justify  this  mode  of  cure  ;  and  that  he  should  be 
ready  to  reject  without  hesitation  those  cases  which  do  not  properly 
come  within  its  scope.  The  choice  of  a  mode  of  cure  in  a  given  case 
is  not  a  matter  to  be  decided  by  personal  preference  or  by  partisan 
feeling — it  must  be  determined  entirely  in  the  patient's  interest,  and 
after  careful  study  of  the  case,  especially  in  reference  to  the  following 
points,  which  include  the  conditions  usually  presented,  favorable  or 
otherwise,  to  the  crushing  operation  :  the  period  of  life  ;  general  or 
local  disease,  especially  of  bladder  and  urethra  ;  degree  of  tolerance  of 
instrumental  manipulation  ;  size  and  quality  of  the  calculus. 


282  STONE  IN  THE  BLADDER. 

A  few  words  will  be  necessary  on  each  of  these  points  : 

The  age  of  the  patient  will  determine  the  mode  of  cure  in  about 
one  half  of  tlie  cases  which  present  themselves  in  general  practice  ;  for 
the  most  reliable  statistics  teach  that  '*onc  half  the  entire  number  oc- 
curs before  the  thirteenth  year  is  com])leted."*  Now  the  limited 
proportions  of  the  male  urethra  before  puberty,  the  excessive  sensibil- 
ity of  the  child's  bladder,  and  the  want  of  docility  and  self-control  at 
this  time  of  life  are  all  unfavorable  to  lithotrity  ;  Avhile  it  is  just  in  this 
class  of  cases  that  the  cutting  operation  has  attained  its  greatest  suc- 
cess— a  mortality  varying  from  one  in  eleven  to  one  in  twenty-eight, 
the  mean  mortality  of  the  whole  period  of  life,  below  the  age  of  four- 
teen, being  about  one  in  fifteen.  As  a  rule,  then,  to  which  exceptions 
are  rare,  lithotomy  is  the  i)referable  method  of  cure  for  male  children 
under  the  age  of  fourteen.  The  exceptions  are,  when  the  stone  has 
been  discovered  just  after  its  formation,  while  still  very  small,  so  that 
one  or  two  operations  with  a  slender  lithotrite  will  certainly  remove  it. 
In  these  operations  an  anesthetic  would  be  required.  In  the  future 
progress  of  lithotrity  these  exceptions  may  become  more  numerous,  f 

III  case  of  general  disease,  involving  vital  organs  and  threatening 
life,  the  performance  of  any  surgical  023eration,  with  the  ol)ject  of 
removing  a  stone  from  the  bladder,  must  necessarily  be  regarded  as 
an  exceptional  proceeding,  warranted  only  by  the  certainty  of  being 
able  to  remove  immediate  danger  to  life,  or  to  relieve  extreme  jiain, 
not  otherwise  relievable,  with  the  prospect  of  prolonging  life  for  a 
limited  period.  Where  any  operation  is  determined  upon  under  these 
circumstances,  it  would  probably  be  more  judicious  to  take  the 
chances  of  securing  relief  at  once  by  lithotomy.  An  excei)tion  here 
would  be  a  case  in  which  there  was  great  tolerance  of  the  bladder, 
such  as  generally  accompanies  atony  of  that  organ — a  condition  in 
which  the  practiced  lithotritist  could  do  pretty  much  as  he  pleased. 

By  local  disease  of  the  urinary  organs  is  understood,  practically, 
stricture  of  the  urethra,  enlargement  of  the  prostate,  intense  or  jier- 
sistent  cystitis,  and  organic  alteration  of  the  kidneys. 

The  existence  of  confirmed  organic  stricture  at  one  or  more  points 
of  the  urethra  is  a  serious  impediment  to  lithotrity.  A  fully  distensi- 
ble canal,  with  healthy  walls,  is  an  indispensable  requisite  for  the  easy 
introduction  of  the  instruments  employed  in  crushing  calculus,  as  well 
as  for  the  ready  escape  of  the  detritus  resulting  from  the  operation. 
The  question  may  be  asked,  Can  not  the  stricture  be  cured,  and  the 

*  Thompson,  "  Practical  Lithotomy  and  Lithotrity." 

f  This  hope  has  been  verified.  D.  F.  Kecgan,  "  Lancet,"  December  4,  1886,  p.  1068, 
"  Litholapaxy  in  Male  Children,"  etc.,  gives  a  table  of  fifty-eight  cases — youngest,  one  year 
and  three  quarters ;  oldest,  fourteen  ;  average  age,  six  and  a  half  years — all  finished  in  one 
sitting,  except  one  cai?e,  which  required  three.  Smallest  stone,  five  grains  ;  largest,  seven 
hundred  grains,  in  a  boy  of  nine  and  a  half ;  average,  one  hundred  and  eight  and  a  half 
grains — all  cured  but  one,  a  boy  of  four. — Keyes. 


CHOICE  OF  METHOD  OF  CURE.  283 

patient  afterward  be  subjected  to  lithotrity  ?  The  answer  is,  to  restore 
the  walls  of  a  strictiired  urethra  to  their  original  suppleness,  distensi- 
bility,  and  smoothness  of  surface,  is  a  remote  and  rather  uncertain 
possibility,  if  indeed  it  be  a  possibility;  and  the  arrest  of  fragments 
at  any  point  in  the  urethra  where  a  stricture  has  once  existed  is  an 
accident  always  liable  to  occur.  Yet  there  are  instances  on  record  in 
which  this  impediment  has  been  overcome  with  more  or  less  success  ; 
and  a  surgeon  of  tact  and  experience  may,  in  a  case  entirely  favorable 
in  other  respects,  successfully  compromise  with  this  disadvantage  when 
existing  in  a  moderate  degree.*  In  old  cases  of  stricture,  where  stone 
has  formed  in  the  bladder  cystitis,  of  more  or  less  intensity  is  neces- 
sarily present ;  and  here  a  resort  to  the  knife  is  imperative — for  an 
additional  reason  also,  that,  by  a  modification  of  median  lithotomy, 
the  stricture  may  be  possibly  treated  successfully  by  external  incision 
at  the  same  time  that  the  calculus  is  removed  from  the  bladder. 

In  1869  a  gentleman  with  an  old  and  obstinate  stricture,  complicated  with  chronic 
cystitis,  came  to  New  York  for  relief.  It  was  with  diflSculty  that  the  smallest  bougies 
could  be  introduced  into  the  bladder.  From  the  constantly  recurring  exacerbations  of 
intense  pain  in  micturition,  and  the  occasional  presence  of  phosphatic  sand  in  the  urine, 
the  suspicion  arose  that  a  stone  had  formed  in  the  bladder.  As  the  stricture  was  not 
amenable  to  treatment  by  dilatation,  in  consequence  of  the  presence  of  false  passages 
and  extreme  sensibility  of  the  urethra,  a  very  small  whalebone  bougie  was  introduced  to 
serve  as  a  guide,  and  on  this  division  of  the  stricture  was  effected  by  perineal  section, 
and  the  incision  afterward  prolonged  to  the  neck  of  the  bladder,  whence  were  removed 
two  phosphatic  calculi  of  moderate  size,  which  had  been  promptly  discovered  after  divis- 
ion of  the  stricture.  The  patient  made  a  good  recovery,  and  learned  to  introduce  for  him- 
self a  full-sized  steel  sound,  No.  17. 

It  would  have  been  impossible  to  treat  such  a  case  by  lithotrity. 

Enlargement  of  the  prostate  is  not  an  objection  to  lithotrity  so  long- 
as  it  offers  no  obstacle  to  the  ready  passage  of  the  necessary  instru- 
ments into  the  bladder.  Nor  is  the  condition  of  atony,  or  impaired 
contractility  of  the  bladder,  so  common  a  complication  of  the  enlarged 
prostate,  to  be  regarded  as  an  unfavorable  circumstance.  On  the  con- 
trary, it  is  in  cases  of  this  kind  that  the  trained  lithotritist  is  some- 
times able  to  manage  successfully  the  largest  calculi  removable  by  the 
crushing  operation.  [These  remarks  refer  to  old-fashioned  lithotrity. 
— Ketes.] 

Chronic  cystitis  of  a  very  intense  and  persistent  character,  ivithout 
stricture  or  any  obvious  cause  save  the  presence  of  the  stone,  is  a  valid 
objection  against  lithotrity.  f  While  the  bladder  is  acutely  intolerant 
of  its  contents,  suflBcient  urine  can  not  accumulate  within  its  cavity 
to  afford  an  area  in  which  the  lithotrite  can  be  safely  manoeuvred. 
Apart  from  the  danger  of  still  further  increasing  the  intensity  of  the 

*  Walter  J.  Coulson,  F.  R.  C.  S.,  op.  cii.,  p.  52,  rf  seq.,  has  cases  illustrative  of  this 
point. 

f  This  is  no  longer  true,  since  litholapaxy  has  taken  the  place  of  lithotrity. — Ketes. 


284  STOXE  IX  THE  bladder. 

iuflammation  by  interference,  tlie  simple  attempt  to  introduce  the 
instrument  into  the  bladder  is  liable  to  bring  on  acute  spasmodic  con- 
tractions, by  which  its  contents  are  forcibly  ejected.  Means  must  be 
employed,  therefore,  to  lower  the  grade  of  the  inilammation,  to  im- 
prove the  quality  of  the  urine,  and  to  diminish  the  fro(iucncy  of  the 
calls  to  urinate,  before  the  feasibility  of  lithotrity  can  be  determined  ; 
and,  if  this  improvement  can  not  be  accomplished  after  a  reasonable 
trial,  the  crushing  operation  must  be  abandoned.  There  is  a  wide 
margin  here  for  skill  and  tact  in  the  enii)loyment  of  medical  treat- 
ment to  improve  the  condition  of  the  bladder.  When  a  degree  of  tol- 
erance has  been  attained  in  which  the  intervals  between  the  calls  has 
reached  an  hour  and  a  half,  the  contents  of  the  bladder  equaling  about 
three  ounces,  and  the  improvement  is  iirogrcssive,  then  the  use  of 
instruments  in  the  gentlest  manner  may  be  tried.  Cases  are  on  rec- 
ord in  which,  where  the  calculus  has  been  small  and  the  patient  other- 
wise healthy,  the  fact  having  been  clearly  established  that  the  cystitis 
was  being  kept  up  solely  by  the  stone's  presence  in  the  bladder,  an- 
aesthesia has  been  employed,  and  the  calculus  removed  successfully  at 
one  operation.  This  is  an  exceptional  application  of  lithotrity,  justi- 
fiable only  in  the  hands  of  a  master  of  the  art.* 

Long-continued  obstructive  disease  of  the  urinary  organs,  cither 
from  urethral  stricture  or  enlarged  prostate,  is  often  complicated,  not 
only  by  chronic  cystitis,  but  by  deeper  lesions,  involving  vital  organs  ; 
dilated  and  tortuous  ureters,  evidences  of  chronic  pyelitis  of  low  grade, 
with  atrophy  and  other  profound  alterations  of  the  kidneys.  During 
life,  however,  the  existence  of  these  serious  complications  can  not  be 
made  out  with  any  absolute  degree  of  certainty ;  habitual  tenderness 
on  deep  pressure  over  the  kidneys,  tendency  to  chill  on  slight  provoca- 
tion, increased  frequency  of  pulse  toward  evening,  nausea  and  cajiri- 
cious  appetite,  with  feeble  digestion,  and  similar  evidences  of  failing 
health,  which  can  not  be  otherwise  adequately  explained,  are  symp- 
toms from  which  the  existence  of  these  lesions  may  be  inferred.  Any 
operation  undertaken  upon  a  person  in  this  condition  is  liable  to  be 
followed  by  rapidly  fatal  symptoms,  due  most  probably  to  urEemia. 

The  form  of  renal  degeneration  known  commonly  as  Bright's  dis- 
ease, a  malady  entirely  different  in  its  pathological  signification  from 
that  sequence  of  morbid  changes  due  to  urinary  obstruction  which  has 
just  been  described,  seems,  in  fact,  to  be  rather  rarely  associated  with 
calculous  disease.  It  often  occurs  in  connection  with  cardiac  lesion, 
and  is  readily  recognizable  by  unmistakable  symptoms,  of  which  the 
most  characteristic  are  the  presence  of  albumen  in  the  urine,  and  of 
casts  of  the  uriniferous  tubes  in  its  sediment.  When  present,  it  con- 
stitutes a  grave  objection  to  operative  interference  of  any  kind. 

What  we  require  to  know  especially  concerning  the  stone,  in  the 

*  Modem  experience  in  litholapaxy  always  justifies  it. — Keyes. 


CHOICE  OF  METHOD   OF  CURE.  285 

next  place,  is  its  size  and  degree  of  hardness  ;  or,  if  there  be  more  tliun 
one,  their  aggregate  volume,  so  that  the  amount  of  debris  which  would 
result  from  their  crushing  might  be  estimated  with  some  approach  to 
accuracy  ;  and  this  knowledge,  already  attained  in  some  degree  by  ex- 
ploration with  the  lithotrite,  is  to  be  used  conjointly  with  what  has 
been  learned  as  to  the  condition  and  degree  of  tolerance  of  the  blad- 
der ;  for  the  surgeon  would  be  justified  in  attacking  a  much  larger 
phosphatic  calculus  in  the  tolerant  or  atonized  bladder  of  an  old  man 
than  one  of  uric  acid  of  smaller  size  in  the  more  irritable  bladder  of  a 
younger  subject.  Again,  a  calculus  of  uric  acid  breaks  into  wedge- 
shaped  fragments,  with  acute  angles  ;  and  the  mulberry  calculus,  from 
its  extreme  hardness,  yields  but  few,  and  consequently  large  fragments, 
with  very  sharp  edges  ;  the  result  of  a  crushing  in  either  case  would 
involve  more  risk  of  subsequent  inflammation  than  the  less  irritating 
and  more  pulverulent  detritus  of  a  phosphatic  stone.  It  becomes 
obvious,  therefore,  that  in  fixing  a  rule  which  shall  determine  the 
choice  between  the  crushing  and  cutting  operations,  as  based  upon  the 
size  of  the  stone,  a  standard  must  be  adopted  which  shall  vary  with 
its  quality.  It  is  safe  to  say  that  all  stones  under  an  inch  in  diameter 
may  be  crushed  ;  but  it  would  not  be  judicious  to  conclude  that  all 
stones  beyond  this  size  must  of  necessity  be  reserved  for  lithotomy. 
Here  is  room  for  the  exercise  of  sound  judgment,  and  to  this  end  an 
accurate  diagnosis  must  be  made  as  to  the  nature  of  the  calculus,  as 
well  as  to  the  condition  of  the  bladder.  For  this  purpose,  careful 
microscopic  study  of  the  patient's  urine,  and  inquiry  as  to  when  it 
first  became  turbid,  and  what  changes  it  has  undergone,  will  give 
much  assistance.  The  habitual  presence  in  the  urinary  sediment  of 
the  octahedral  crystals  of  oxalate  of  lime,  the  prisms  of  the  trij^le  phos- 
phate, of  the  common  and  varied  crystals  of  uric  acid,  or  of  the  puru- 
lent sediment  of  the  amorphous  urates,  would  add  much  certainly  to 
the  diagnosis  of  the  probable  nature  of  the  calculus  ;  while  a  close  and 
searching  inquiry  into  the  history  of  the  patient,  his  antecedents,  his 
earlier  symptoms,  and  their  different  phases  as  the  malady  progressed, 
the  possible  occurrence  of  previous  attacks  of  renal  colic,  and  the 
habits  of  the  patient,  as  influencing  them,  with  a  review  of  his  inher- 
ited or  acquired  constitutional  peculiarities,  could  hardly  fail  to  elicit 
valuable  information. 

The  probability  of  a  central  nucleus  of  uric  acid,  from  its  extreme 
frequency,  is  very  great ;  but  the  possibility  of  finding  a  nucleus  in 
the  shape  of  a  foreign  substance  which  had  got  into  the  bladder  from 
without,  such  as  a  fragment  of  bone  or  wood,  which  it  would  be  im- 
possible to  crush,  is  not  to  be  forgotten.* 

*  In  the  collection  of  calculi  in  the  Museum  of  the  Royal  College  of  Surgeons  of  Lon- 
don, according  to  the  catalogue,  out  of  649  calculi,  212  are  composed  of  uric  acid  alone, 
and  in  65  others  it  forms  the  nucleus.     Urates  are  given  as  constituting  the  entire  cal- 


286  TREATMENT  OF  STONE  OTHER  THAN  RADICAL. 


CHAPTER  XY. 

TEEATMEXT  OF  STONE  OTHER  THAN  EADIGAL. 

The  Preventive  Treatment  of  Stone. — The  Electrolytic  Tri'iitment  of  Stone.— The  Solvent  Treat- 
meat  of  Stoue,  General  and  Local.— The  Palliative  Treatment  of  Stone. 

Efforts  may  be  made  looking  toward  the  prevention  of  stone 
formation  in  two  directions  :  (1)  In  correcting  an  inherited  or  dia- 
thetic tendency  to  acid  primary  stone  formation,  wlien  this  is  knowai 
to  exist ;  (2)  in  overcoming  local  physical  conditions  vrhose  continu- 
ance threatens  the  complication  stone  as  a  secondary  symptom — alka- 
line, secondary  stone. 

When  litliiasis  exists,  when  a  patient  constantly  passes  acid  con- 
centrated urine  more  or  less  charged  with  crystals,  when  he  has  already 
passed  one  kidney  stone  and  fears  the  formation  of  another,  what 
may  be  done  to  aid  him  ? 

I  need  not  here  discuss  the  colloidal  theory,  because  that  theory  has 
not  yet  reached  the  practical  stage.  The  scientific  writings  of  Ord 
and  Carter  are  full  of  suggestion,  but  another  master  must  teach  us 
how  to  apply  them. 

The  best  that  can  be  done  practically  at  present  may  be  accom- 
plished by — 

1.  Dietetics. 

2.  Exercise. 

3.  Encouraging  elimination  by  other  aveuues. 

4.  Diluting  the  urine  constantly. 

5.  The  use  of  solvents,  and  attempts  to  dilute  the  colloids. 

(1)  Thompson,  who  has  given  this  matter  much  attention,  believes 
that  the  uric-acid  formation  lies  essentially  in  the  liver,  and  that  it  is 
by  correcting  that  organ  that  we  may  hope  to  overcome  the  diathesis. 
He  adopts,  in  the  main,  the  Carlsbad  notions,  and  cuts  off  sugar,  fat, 
and  alcohol,  rather  than  the  meats,  and,  in  truth,  such  a  dietary  usu- 
ally proves  more  effective  than  the  old-fashioned  one,  which  interdicted 

culi  in  14,  and  the  nucleus  of  187  out  of  the  649 ;  13  are  composed  entirely  of  oxalate  of 
lime ;  it  forms  the  nucleus  in  62. 

In  a  successful  case  of  lithotomy  which  occurred  in  this  city  during  the  late  war, 
under  the  care  of  Drs.  Livingston  and  Markoe,  a  quadrangular  fragment  of  bone  was 
found  in  the  center  of  the  calculus.  It  had  been  broken  off  by  a  bullet,  which  had  passed 
completely  through  the  bladder,  leaving  the  piece  of  bone  to  become  the  nucleus  of  a 
stone.  The  size  of  this  fragment  was  too  great  to  permit  its  withdrawal  through  the  ure- 
thra in  the  jaws  of  a  lithotrite,  and  its  consistence  too  solid  and  resisting  to  allow  of  its 
being  crushed. 


PREVENTIVE  TREATMENT.  287 

nitrogenized  food  because  uric  acid  was  a  nitrogenizcd  product.  Ikit 
the  foolishness  of  this  is  apparent  when  we  reflect  that  tliore  is  neces- 
sarily enough  nitrogen  eliminated  every  day  in  the  urine  to  supply 
uric  acid  without  end,  provided  only  the  colloidal  and  other  conditions 
are  present  upon  which  the  formation  of  these  crystals  depends. 

Practically,  then,  it  is  found  that  a  proper  diet  consists  of  meat, 
poultry,  fish,  eggs,  bread,  and  all  the  cereals,  all  the  fruits  and  roots, 
green  vegetables  and  salads,  with  butter  and  milk  in  moderation — the 
latter  notably  in  some  instances,  in  my  opinion,  keeps  up  uric-acid 
tendencies.  If  any  of  the  above-mentioned  articles  proves  hard  to 
digest,  that  fact  alone  is  enough  to  condemn  it  in  the  individual  case. 

Sugar  is  harmful ;  most  wines  and  liquors  are  pernicious ;  some- 
times a  little  light  white  wine  is  allowable,  or  gin  or  old  whisky  in 
selected  cases.  Heller  proved  that  an  exclusive  diet  of  rye  bread  caused 
all  uric  acid  to  disappear  from  the  urine,  this  substance  being  re- 
placed by  hippuric  acid,  a  solution  of  which  is  a  natural  solvent  of 
uric  acid. 

(2)  Exercise,  probably  by  improving  digestion  and  giving  plenty 
of  oxygen  to  the  blood  and  tissues,  is  a  factor  of  such  generally  recog- 
nized value  in  preventing  uric-acid  formation  that  its  mention  alone 
is  required.     Discussion  is  unnecessary. 

(3)  The  liver  has  a  large  share  in  uric-acid  formation,  and,  by  pre- 
venting it  from  becoming  what  is  called  torpid,  a  long  stride  is  made 
in  the  preventive  treatment  of  stone.  The  function  of  the  bowels 
should  therefore  be  closely  attended  to,  and  occasionally  encouraged,  if 
need  be,  by  a  blue  pill  or  some  calomel,  or  the  combination  of  a  mer- 
curial with  a  few  grains  of  compound  rhubarb  pill.  Added  to  this,  a 
course  of  Glauber  salts  may  be  given  occasionally,  or  small,  graded,  pro- 
longed courses  of  the  sulphate-of-soda  bitter  waters  (Hunjadi,  Fried- 
erichshall).  Garrod  *  speaks  strongly  in  favor  of  long  courses  of  the 
benzoates  of  sodium  and  potassium  for  the  purpose  of  acting  as  uric- 
acid  solvents. 

(4)  Many  persons  prone  to  discharge  uric  acid  and  urates  in  excess, 
and  to  have  habitually  concentrated  urine,  are  not  free  drinkers  of  water, 
and  in  the  case  of  such  persons  some  good  may  be  done  by  encoui-aging 
them  to  take  a  glass  of  water  between  meals  and  another  on  retiring. 
This  renders  the  urine  by  so  much  the  more  dilute,  and  by  as  much  it 
militates  against  precipitation  of  the  urinary  salts.  Filtered  rain-water 
is  better  than  ordinary  water  for  this  purpose.  Distilled  water  is  ex- 
cellent, and  some  of  the  mineral-spring  waters  better  still — such  as 
Wildungen,  Poland,  Bethesda — the  still  natural  waters ;  after  being 
charged  with  carbonic-acid  gas,  their  diuretic  property  is  much  les- 
sened. 

(5)  A  quick  way  to  dissolve  acids  in  the  urine  is  to  administer 

*  "  Uric  acid,"  etc.,  "Lancet,"  April  21,  1883,  p.  670. 


258  TREATMENT   OF  STONE   OTHER   THAN   RADICAL. 

alkaline  medicines,  particularly  such  as  have  also  a  diuretic  efifect,  such 
as  the  acetate  or  the  citrate  of  potash.  Here  belong  also  all  the  alka- 
line salts  and  the  alkaline  waters,  such  as  Vichy  and  Butralo  Lithia. 
As  preventive  means  to  stone  formation,  the  alkaline  method  is  defect- 
ive in  that  it  is  by  no  means  essential,  and  if  long  continued  in  many 
instances  it  finally  ceases  to  act,  or  may  have  the  further  harmful 
effect  of  disturbing  digestion,  and  sometimes  directly  causing  ana.nnia. 
When  alkaline  medicines  are  given,  it  must  be  remembered  that  they 
produce  their  maximum  effect  for  good  in  a  given  quantity  if  admin- 
istered about  two  hours  after  the  end  of  a  meal.  The  boro-citrate  of 
magnesia  in  about  ten-grain  doses  is  well  borne  if  a  long  course  of 
alkaline  medicine  is  desired. 

The  crystals  of  oxalate  of  lime  do  not  cease  to  appear  under  an 
alkaline  course.  They  constantly  occur  in  connection  with  jihos- 
phaturia.  Dilute  mineral  acids,  nerve  tonics,  bitters,  exercise,  and 
air,  are  the  best  means  with  which  to  fight  this  tendency.  Beale* 
believes  that  the  free  use  of  carbonate  of  ammonium  will  in'evcnt 
cystine  formations. 

To  dilute  the  colloids,  which  seem  to  preside  over  crystallization, 
all  that  at  present  can  be  done  is  to  keep  the  urine  dilute  and  bland, 
keep  digestion  perfect,  prevent  catarrhal  conditions  of  the  stomach 
and  intestine,  and  avert  fever — or  feverishness  from  whatever  cause. 
Whether  hydrangea  is  valuable  in  this  direction  or  not,  I  have  not  yet 
decided.  Cider  habitually  used  seems  to  serve  a  good  end,  possibly  in 
this  direction. 

The  preventive  measures  useful  against  secondary  phosphatic  stone 
formation  are  better  known  and  more  certain  of  success.  No  amount 
of  phosphates  in  the  urine  can  cause  secondary  alkaline  phosphatic 
stone.  The  latter  only  occurs  in  connection  with  a  catai'rhal  state  of 
the  mucous  membrane  somewhere  along  the  urinary  tract.  There- 
fore, the  means  of  prevention  of  secondary  stone  include  the  surgical 
treatment  of  all  obstructive  urethral  disease  (stricture),  of  enlarged 
prostate,  the  removal  of  tumors,  of  all  nuclei,  of  foreign  bodies,  the 
relief  of  residual  urine  by  the  timely  employment  of  the  catheter,  the 
treatment  of  vesical  catarrh  by  irrigation,  medicated  injections,  etc. 
Added  to  this,  some  good — much  good,  indeed — may  be  attained  in  some 
cases  by  the  judicious  use  of  a  milk  diet,  of  abundant  diluent  drinks, 
of  tonics,  of  alkalies  or  acids  as  indicated,  and  sometimes  of  such 
medicines  as  the  balsams,  the  bcnzoates  or  benzoic  acid,  the  salicy- 
lates, naphthaline,  etc. 

The  Electrolytic  Treatment  of  Stone. — Although  the  electric  cur- 
rent influences  crystallization,  and  although  Bouvier-Dcniortiers  and 
Dumas  and  Prevost,  as  well  as  Erckmann,  have  shown  that  stone  may 
be  pierced  and  disintegrated  by  the  galvanic  current,  yet  the  method 

*  "Lancet,"  August  30,  1884,  p.  263. 


SOLVENT   TIIEATMENT.  289 

is  a  failure  for  all  practical  purposes,  and  not  worthy  of  general  adop- 
tion under  any  known  circumstances. 

The  Solvent  Treatment  of  Stone. — Since  Pliny's  ashes  of  snail-shells 
even,  to  the  present  day,  the  wise  and  foolish  alike  have  searched  un- 
ceasingly for  something  which,  taken  by  the  mouth,  might  be  capable 
of  dissolving  a  stone  in  the  kidney  or  bladder,  and  the  substance  has 
not  been  found.  The  Joanna  Stephens  remedies  worked  wonders  in 
the  last  century,  until  Parliament  bought  the  secret  for  £5,000,  after 
which  they  quickly  fell  into  disuse  and  are  now  forgotten.  Each  of 
the  four  patients,  whose  cures  were  attested  by  the  trustees  appointed 
by  government  to  investigate  the  matter,  died  with  stone  in  the 
bladder,  as  proved  by  autopsy  in  each  case. 

It  is  quite  plain  that  secondary  phosphatic  stones,  being  alkaline 
and  needing  an  acid  solvent,  can  not  be  dissolved  by  any  internal 
medicine.  They  may  be  acted  upon  by  local  injections  of  acids,  but 
not  so  effectively  as  by  other  means,  which  require  even  less  instru- 
mentation. 

The  most  serious  efforts  of  modern  times  to  dissolve  small  acid 
stone  (in  the  kidney)  by  medicine  taken  into  the  stomach  are  those 
of  Koberts*  and  Garrod,f  of  England,  and  they  are  most  praiseworthy. 
The  former  uses  long  courses  of  the  citrate  (gr.  xl  to  1  every  three  to 
four  hours)  of  potash,  substituting  bicarbonate  if  the  citrate  j)roves 
too  diuretic ;  the  latter  uses  the  same  salts  of  lithium  in  a  smaller 
dose. 

Beale  J  uses  carbonate  of  ammonium  to  prevent  cystine  precipita- 
tion, gr.  1  three  times  a  day  in  one  case  for  three  years. 

All  these  means  are  in  a  good  direction,  but  there  is  little  hoj^e  of 
effecting  any  serious  good  with  them  if  the  stone  is  large  enough  to 
be  worthy  of  the  name.  Yet  the  treatment  frequently  gives  comfort 
to  the  patient,  and  is  not  to  be  wholly  condemned.  Mineral  waters 
sometimes  disintegrate  a  stone  by  causing  its  spontaneous  fracture. 

The  palliative  treatment  of  stone,  in  cases  not  fit  for  operation,  is 
a  Judicious  combination  of  alkalies,  rest,  milk  diet,  anodynes,  and 
tonics,  addressed  to  the  individual  needs  of  each  case,  with  such  use 
of  the  catheter,  vesical  irrigation,  and  medicated  injections  as  may  be 
called  for. 

*  "  Urinary  and  Renal  Diseases,"  second  American  edition,  pp.  298-321,  18'J'2. 
f  "Lancet,"  April  21,  1883,  p.  669. 
X  "Lancet,"  August  30,  1884,  p.  363. 


19 


290  LITHOLAPAXY. 


CHAPTER  XYL 
LITHOLAPAXY. 

Modem  Improved  Lithotrity.— Cases  suitable  for  this  Operation.— Instruments  used,  and  their 
Method  of  Emploj'iuent.— After-treatment.— Complications.— Litholapnxy  in  Women.— Kelapse. 

Lithotrity  is  dead,  having  disappeared  from  surgery  as  its  bril- 
liant child  and  successor,  litholapaxy,  established  its  claims.  History 
and  discussion  on  matters  of  this  sort  are  out  of  place  here.  I  have 
written  what  I  have  to  say  on  these  matters  elsewhere.*  I  must  here 
confine  myself  to  conclusion,  since  there  is  no  space  for  controversy. 
A  stone  in  the  bladder  to-day  must  either  be  let  alone,  removed  by 
litholapaxy,  median  or  lateral  lithotomy,  or  the  suprajjubic  operation. 
Litholapaxy  is  suitable  to  all  ages.  Children  less  than  two  years  old 
have  been  successfully  operated  upon  by  it,  and  old  men  of  ninety 
"with  equal  success.  It  has  given  better  results  statistically  at  both 
ends  of  life  than  any  other  operation  for  the  removal  of  stone,  and  its 
position  is  now  established  in  all  j)arts  of  the  world.  To  its  discoverer, 
Prof.  H.  J.  Bigelow,  of  Boston,  in  my  opinion,  the  surgery  of  stone 
owes  more  than  to  any  other  man  in  this  or  any  other  age.  It  is  the 
outcome  of  mechanical  ingenuity  adapting  suitable  means  to  a  recog- 
nition of  the  fact,  not  before  api)reciated,  that  the  urethra  may  be 
widely  distended,  and  the  bladder  tolerate  any  amount  of  prolonged 
manipulation  skillfully  performed,  provided  only  that  all  the  dehriH  be 
taken  away  and  the  bladder  left  empty  after  the  operation.  This  is 
litholapaxy — to  catch  the  stone  with  an  instrument  passed  through  the 
urethra,  to  fragment  it  sufficiently  for  the  detritus  to  pass  out  through 
a  tube,  and  to  suck  out  the  debris  by  some  suitable  apparatus. 

Nearly  every  operator  of  i^rominence  has  his  own  lithotrite,  and 
many  of  them  have  devised  washing  bottles  and  special  tubes.  With 
any  form  of  apparatus  the  operation  may  be  done,  and  with  more  or 
less  rapidity  and  success,  according  to  the  operator.  On  these  differ- 
ent questions  it  is  impossible  to  enter  freely  here,  as  it  is  impossible  to 
describe  all  the  instruments  employed  at  various  hands.  I  shall  only 
describe  here  Bigelow's  instrument,  out  of  respect  to  its  author;  my 
own  lithotrite,  which  I  believe  to  be  as  safe  and  more  easy  to  use  ; 
Bigelow's  bottle,  which  is  by  far  the  most  perfect  that  I  have  seen, 
and  his  tubes,  with  two  of  my  own. 

Cases  SuitaMe  for  Opercdion. — No  age  is  a  bar  to  litholapaxy. 
Any  stone  may  be  crushed  if  it  can  be  caught  in  the  jaws  of  the 

*  "International  Encyclopaedia  of  Surgery,"  vol.  vi,  p.  145  ct  scq. 


INSTRUMENTS   REQUIRED. 


201 


litliotritc.  I  have  crushed  a  stone  two  inches  in  one  oi"  its  diumeters. 
The  stone  may  be  so  hard  that  the  lithotrite  can  not  break  it,  but  I 
have  easily  crushed  an  oxalate-of-limc  stone  an  inch  in  diameter; 
modern  instruments  are  made  of  great  strength.  Multiple  stone  is 
particularly  suitable  for  litholapaxy.  There  is,  in  short,  no  contra- 
indication except  very  great  size  of  the  calculus  or 
phenomenal  hardness,  and  such  conditions  as  a 
foreign  body  for  a  nucleus  unsuitable  for  crushing 
(glass,  lead),  and,  finally,  concomitant  conditions, 
tumor,  intense  vesical  inflammation  calling  for  sub- 
sequent drainage,  etc. 

Preparatio7i  of  the  Patient. — A  little  rest  in 
bed,  a  day  or  two  if  possible,  is  a  proper  part  of  the 
preparation  for  litholapaxy.  The  patient  should  be 
freely  flushed  with  some  bland  diuretic  water  (Po- 
land, Bethesda),  and,  if  possible,  habituated  to  a 
milk  diet,  which  will  serve  him  well  after  his  opera- 
tion. He  may  take  alkalies  or  benzoates  if  the 
urine  calls  for  them,  and  Just  before  his  operation 
his  intestinal  tract  should  be  cleared  out.  I  have 
abandoned  the  use  of  quinine  before  the  operation 
in  most  cases.  I  have  lost  faith  in  its  power  to 
prevent  chill. 

Instruments  required. —  The  essential  instru- 
ments for  litholapaxy  are  a  lithotrite,  a  washing 
bottle,  and  tube.  It  is  desirable  to  have  at  least 
two  lithotrites,  a  light  and  a  heavy  one,  and  a  num- 


Fia.  78. 


Fig.  79. 


Fig.  80. 


ber  of  tubes.  An  old  operator  never  works  without  having  two  bottles, 
for  one  may  give  out  at  any  time  and  ruin  his  operation  unless  a  com- 
panion instrument  is  at  hand.     It  is  proper  also  to  have  a  few  cathe- 


292 


LITHOLAPAXY. 


ters  aud   sounds,   a  searcher,  a  pus  basiu  and  ball  syringe,  rubber 
cloth,  etc. 

Bigelow's  lithotrite  (Fig.  78)  works  by  a  wrist  motion  ujion  an  egg- 
shaped  handle  ;  the  jaws  are  heavy  (Figs.  79,  80) ;  the  male  blade  has 
blunt  indentations,  the  female  blade  is  non-fenestrated.  Admirable 
work  can  be  done  with  this  instrument,  and,  doubtless,  those  who 
become  familiar  with  the  wrist  motion  like  it  as  well  as  they  do  the 
wheel.  Some  of  the  instruments  have  an  extra  curve  at  the  extreme 
tip  of  the  female  blade  to  facilitate  the  passage  of  the  instrument 
through  a  large  prostate.  I  have  used  an  instrument  with  this  extra 
tip,  and  find  it  sometimes  rather  a  disadvantage  when  small,  flat  pieces 

of  stone  are  to  be 
picked  up  upon  the 
floor  of  the  bladder, 
because    with     the 
new  curved  tip  the 
jaw  of  the  female 
blade  is  lengthened. 
I   always  use  a 
fenestrated    instru- 
ment.     The    male 
blade  is  made  after 
the    Eeliquet    pat- 
tern,     is      rather 
smooth   and    little 
likely  to  do  injury 
except    in  careless 
or  ignorant  hands. 
The  instrument  can 
not  clog.      I  have 
two  sizes  (Figs.  81, 
83).     I  have  also  enlarged  the  wheel  and 
strengthened  the  shaft  above  the  point  pos- 
sessed by  old  lithotrites.     I  sometimes  use 
the  old-fashioned  duck-bill  lithotrite  with 
non-fenestrated  female  blade  to  catch  the 
last  fragment. 

Any  good  instrument  will  do  the 
work,  and  there  are  a  number  now  in  the 
market. 

The  now  perfected  washing-bottle  of 
Bigelow  is,  in  my  opinion,  the  best  in  the  world.  The  washing- 
bottle  has  gone  through  many  evolutions  since  its  prototype  was  de- 
vised in  France  by  Cornay  (the  lUheretie)  in  1845,  and  a  year  later  by 
Sir  Philip  Crampton  in  Dublin.     Even  Bigelow's  bottle  has  so  changed 


Fig.  83. 


Fio.  81. 


METHOD   OF   OPERATING. 


293 


that  its  own  original  would  not  be  suspected  of  bearing  any  relation- 
ship to  it. 

The  bottles  of  Thompson,  Guyon,  Otis,  Hill,  and  others  all  will 


Fig.  83. 

work,  but  none  so  well,  in  my  hands,  as  the  instrument  of  Bigelow 
(Fig.  83). 

Bigelow's  tubes  I  find  also  as  good  as  those  of  any  other  device.  I 
prefer  the  curved  tubes  for  common  use  in  old  men,  as  I  think  their 
introduction  bruises  the  prostate  less  than  the  straight  tube. 

I  have  devised  a  straight  tube  (Fig.  84),  for  which  I  have  only  to 
say  that,  introduced  and  drawn  out  to  the  vesical  orifice  of  the  urethra, 
and  held  there  very  accurately,  it  will  sometimes  get  out  a  last  frag- 
ment which  a  tube  of  the  same  size,  not  fully  open  at  the  end,  will  not 
deliver.  This  tube  is  not  easy  to  use.  The  surgeon  not  familiar  with 
it  is  quite  sure  to  pull  its  open  end  out  into  the  prostatic  sinus,  and 
then  wonder  why  it  does  not  work.  It  has  a  wooden  obturator,  armed 
with  a  washer  and  a  stop-cock,  which  allows  its  use  without  wetting 
the  bed — a  thing  hardly  possible  with  the  ordinary  straight- tube.  It  is 
otherwise  a  simple  tube  open  from  end  to  end. 

I  have  constructed  another  tube  also  with  washer  and  stop-cock, 
which  for  all  purposes  of  introduction  is  a  short,  curved  sound.  For 
washing  it  is  a  straight  tube,  and  I  find  that  it  returns  fragments  ad- 
mirably. 

The  Method  of  operating. — The  patient,  etherized,  is  placed  upon 
a  rather  high,  long,  narrow  table,  with  his  hips  slightly  elevated,  the 


294 


LITIIOLAPAXY. 


shoulders  low.  Two  assistants  are  required — one  to  attend  to  the 
ether,  the  other  to  keep  the  washing-bottle  full  and  hand  instruments. 
Through  a  soft  catheter  the  urine  is  drained  away,  and  the  bladder 
thoroughly  washed  with  a  warm  solution  of  borax. 
A  tube  may  be  introduced  to  test  the  caliber  of  tlie 
urethra  if  there  is  doubt  on  this  subject.  A  few 
ounces  of  fluid  are  left  in  the  bladder. 
A  lithotrite,  selected  in  accord- 
ance with  the  size  of  the  stone,  is 
introduced  very  much  after  the  man- 
ner of  a  steel  sound,  except  that, 
after  the  jaws  of  the  instrument  have 
entered  the  membranous  uretlira,  the 
further  introduction  is  effected  by  a 
combination  of  the  motions  of  de- 
pressing the  handle  and  pressing  for- 
ward the  instrument  so  as  to  make 
the  heel  of  the  jaws  of  the  instrument 
slide  along  the  floor  of  the  urethra 
and  prostatic  sinus  until  the  bladder 
is  fairly  entered.  Now  the  instru- 
ment is  slid  back  along  the  floor  of  the 
bladder  until  the  jaws  have  reached 
the  back  wall.  Then,  gentle  tappings 
along  the  side  will  quickly  indicate 
the  position  of  the  stone.  When  the 
latter  is  found,  the  jaws  of  the  litho- 
trite are  turned  away  from  it,  opened, 
returned  while  open  over  the  spot 
where  the  stone  was  found,  and, 
being  gently  closed,  the  stone  will  be 
grasped.  Tlie  screw  power  is  now 
thrown  on  by  the  aid  of  the  button 
in  the  handle,  and  a  half-turn  given 
to  the  screw.  This  fixes  the  stone. 
As  the  half -turn  is  being  given,  the 
Fig  8i  3^^^  °^  ^^^^  lithotrite  are  to  be  gently  ^^^  gg 

moved  away  from  the  bladder-wall 
toward  the  center  of  the  bladder.  If  a  portion  of  mucous  membrane 
has  been  entrapped  along  with  the  stone,  the  operator  instantly  appre- 
ciates it  by  noticing  an  obstacle  to  the  easy  rotation  of  the  shaft  of 
the  instrument.  In  such  case  the  jaws  are  unlocked,  the  stone  allowed 
to  drop  out,  and  another  effort  made  to  catch  it  more  cleanly.  If  the 
instrument  rotates  freely  to  the  center  of  the  bladder,  the  screw  power 
is  firmly  applied,  and  the  stone  fragmented. 


METHOD   OF   OPERATING.  295 

The  lurge  fragments  full  on  cither  side,  and  are  easily  picked  up 
and  again  and  again  fragmented. 

With  a  fenestrated  instrument  there  is  no  occasion  to  stop  to 
clear  the  jaws  or  to  test  them  for  clogging.  The  work  goes  evenly  on 
until  the  operator  presumes  that  he  has  manufactured  enough  diihrin 
to  make  a  creditable  wash,  and  then  a  tube  as  large  as  the  uretlira 
will  admit  is  entered,  the  washing-bottle  coupled,  the  stop-cock  turned, 
and  by  alternate  compressions  and  relaxations  of  the  bulb  the  frag- 
ments are  sucked  up  into  the  bottle  and  fall  into  the  receiver  beneath. 
Care  must  be  taken  to  allow  no  air  to  enter  the  bladder.  In  the  case 
of  small  tubes  this  is  best  averted  by  pausing  in  the  introduction  when 
the  eye  is  yet  within  the  prostatic  sinus,  and  filling  the  tube  by  the 
aid  of  a  small  syringe.  If  the  tube  is  large  the  bottle  is  simply  coupled 
before  the  eye  reaches  the  bladder,  and  the  stop-cock  being  turned  on 
the  operator  waits  a  moment  until  he  hears  the  air  which  was  con- 
tained in  the  tube  rush  up  within  the  bottle,  where  he  knows  that  it 
will  remain  out  of  harm's  way  in  the  air-space  at  the  top.  Now  the 
bulb  is  compressed,  the  prostatic  sinus  is  flooded,  and  the  end  of  the 
tube,  as  it  were,  floated  in  through  the  open  gate  at  the  bladder's 
mouth. 

If  the  tube  becomes  clogged  by  a  fragment,  which  the  competent 
operator  at  once  recognizes  by  the  increased  resistance  to  his  j)ressure 
upon  the  bulb,  a  forcible  compression  of  the  latter  will  often  dislodge 
the  impacted  body.  Should  this  manoeuvre  fail,  the  bottle  must  be 
uncoupled  and  a  catheter  or  other  instrument  run  down  the  tube  to 
drive  out  the  impacted  piece.  Under  no  circumstances  should  a  tube 
be  withdrawn  with  a  sharp  fragment  impacted  in  its  eye.  Such  a 
blunder  entails  certain  scratching  upon  the  deep  urethra,  and  is  more 
likely  to  cause  urethral  fever  and  serious  subsequent  complications 
than  anything  else  which  is  likely  to  occur  in  connection  with  the 
operation. 

The  lithotrite  is  again  introduced,  some  more  debris  made  and 
removed,  and  so  on  until  no  further  click  of  fragments  can  be  heard  as 
the  water  swashes  in  and  out  of  the  bladder,  either  by  the  operator, 
who  at  once  perceives  them,  or  by  the  ear  of  an  assistant  placed  over 
the  bladder  while  the  washing  is  being  kept  up. 

If  a  curved  tube  is  used  and  turned  toward  one  side  of  the  bladder, 
or  even  held  upright  if  the  viscus  contains  but  little  fluid,  as  the 
water  is  rushing  out  into  the  bottle,  the  bladder-wall  is  sucked  against 
the  eye  of  the  tube,  and,  fluttering  there,  gives  several  sharp  clicks, 
which  to  an  unaccustomed  ear  resemble  the  sound  caused  by  a  frag- 
ment of  stone  striking  against  the  tube.  An  old  operator  is  never  so 
deceived.     Finally,  the  bladder  is  drained  and  left  emptj  of  fluid. 

Hgemorrhage  may  be  excessive  during  the  operation,  but  this  is 
extremely  -rare  if  the  operator  is  careful.     In  some  cases  no  care  can 


296  LITHOLAPAXY. 

avert  it,  and  it  may  be  suflficientl}'  profuse  to  cause  the  prudent  sur- 
geon to  terminate  his  operation  before  the  hist  fragment  is  removed, 
leaving  a  little  dcbn's  to  be  taken  away  at  a  future  sitting.  Such  a 
termination,  however,  is  unfortunate,  as  one  of  the  chief  advantages 
of  this  operation  is  that  by  it  the  bladder  is  left  free  from  all  debris 
after  the  operation,  a  potent  factor  in  averting  subsequent  inllamma- 
tion. 

If  the  blades  clog  (which  fenestrated  instruments  avoid),  they  must 
be  freed  by  repeated  sharp  movements  back  and  forth  of  the  male 
blade.  Generally,  such  clogged  blades  have  been  violently  jiullcd  out 
through  the  urethra,  leading  sometimes  to  abscess,  high  urethral  fever, 
even  death.  Ileavily  clogged  blades  in  my  opinion  call  for  perineal 
section  in  the  middle  line,  when  the  charged  jaws  may  be  safely  pulled 
through  the  easily  dilatable  neck  of  the  bladder  and  liberated  in  the 
wound. 

If  an  instrument  breaks  in  the  jaws,  the  patient  should  be  cut  at 
once. 

After-treatment. — This  consists  in  a  free  use  of  mori:)hine  for  one 
or  more  days,  a  little  pilocarpine  subcutaneously  immediately  after  the 
operation,  the  use  of  a  soft  catheter  and  bladder  irrigation  with  borax 
solution  if  there  be  retention  or  if  the  urine  be  ammoniacal  or  putrid, 
milk  diet,  diluent  drinks  (mineral  water),  and  rest  in  bed  for  a  week. 

I  consider  it  unwise  to  let  a  patient  up— especially  an  old  man — 
before  a  week  has  passed.  He  may  seem  well  before  that  time,  but 
his  soreness  may  return,  and  mild  cystitis  occur,  if  he  gets  up  too 
soon.  I  have  in  many  exceptional  instances  turned  my  patient  out  on 
the  second  day — but  I  do  not  think  well  of  this.  I  have  indeed  oper- 
ated in  my  office  several  times  under  cocaine — and  with  no  anaesthetic 
in  the  case  of  small  stone — but  this  again  only  in  exceptional  cases. 

Impacted  fragments  in  the  urethra,  one  of  the  horrors  of  old-fash- 
ioned lithotrity,  should  never  occur  with  this  operation.  If  the  blad- 
der is  left  empty  of  fragments,  such  a  comi^lication  is  obviously  im- 
possible. Should  it  ever  occur,  the  foreign  body  may  be  pushed  back 
into  the  bladder  or  removed  from  tiie  urethra  with  a  Thomj^son's  rapid 
dilator,  or  in  one  of  the  methods  alluded  to  under  that  head  earlier  in 
this  treatise. 

After  litholapaxy  all  the  complications  niay  occur  which  are  found 
with  various  operations  upon  the  urinary  tract,  from  catheterism  up- 
ward. Urethral  fever,  mild  or  pernicious,  retention,  haemorrhage, 
cystitis,  peri-urethral  abscess,  epididymitis,  or  even  the  graver  compli- 
cations, suppression,  surgical  kidney  (pyelo-nephritis),  possibly  even 
pyaemia,  septicaemia  ;  but  as  a  rule  a  careful  operation  has  no  sequence 
but  a  little  temporary  discomfort  for  a  week  or  less,  followed  by  cure. 
I  can  not  remember  when  I  have  had  a  patient  in  bed  longer  than  a 
week  after  litholapaxy. 


TREATMENT   OF  KTONE.  297 

The  operation  is  entirely  applicable  to  women  and  young  female 
children.  I  haye  operated  upon  a  girl  of  four  years,  and  an  old  lady 
past  sixty. 

Relapse. — Relapse  after  litholapaxy  only  is  possible  under  throe 
circumstances.  A  fragment  is  left  by  the  operator.  This  is  to  be 
avoided  by  testing  the  patient  with  the  washing-bottle  and  small  tube 
a  month  after  he  believes  himself  to  be  perfectly  well.  If  a  fragment 
has  been  left,  it  will  then  be  discovered,  and  may  be  easily  taken  away. 

A  new  stone  may  form  upon  a  new  nucleus  which  comes  down 
from  the  kidney.  This  is  not  strictly  a  relapse,  and  the  operation  is 
in  no  way  responsible  for  it.  Phosphatic  re-accumulation  may  occur 
in  old  cases  of  vesical  catarrh,  the  cause  of  which  (notably  enlarged 
prostate)  can  not  be  removed.  Here  again  the  operation  is  not  respon- 
sible, since  the  same  relapses  occur  after  lithotomy. 


CHAPTEE  XYII. 
LITHOTOMY. 


The  Lateral  Operation.— Cases  suitable  for  it.— Instruments  employed.— Operative  Method.— After- 
treatment.— The  Lateral  Operation  in  Children.— The  Median  Operation.— Cases  suitable  for 
it.— Operative  Method.— Complications  of  Lithotomy.— Relapse  after  Lithotomy. 

In  the  consideration  of  the  treatment  of  stone,  the  subject  of 
lithotomy  is  introduced  last,  because  it  is  an  operation  of  far  less  im- 
portance than  its  powerful  rival  litholapaxy  :  to  the  latter  it  is  yearly 
yielding  more  and  more  of  the  cases  which,  by  common  consent,  for- 
merly fell  solely  within  its  own  domain.  That  lithotomy  is  an  impor- 
tant operation,  and  eminently  surgical,  is  undoubted  ;  that  it  requires 
a  cool  head  and  steady  hand  for  its  proper  performance,  none  will  dis- 
pute ;  that  it  is  often  brilliant  in  its  results  is  equally  self-evident ; 
but  the  function  of  the  surgeon  is  not  to  perform  brilliant  operations, 
but  to  cure  disease  and  relieve  pain  with  as  little  risk  to  life  as  possible, 
and  this  litholapaxy  accomplishes  far  more  certainly,  in  the  hands  of 
the  average  operator,  than  does  any  variety  of  lithotomy.*  As  the 
means  of  diagnosis  improve  and  become  more  widely  spread,  stones 
are  detected  earlier,  and  yearly  the  number  of  calculi  is  greater  which 
come  within  the  scope  of  litholapaxy — an  operation  which,  carefully 
and  gently  performed  upon  a  proper  subject,  is  nearly  as  harmless  as 
any  grave  operation  can  be  expected  to  be.  A  mortality  of  not  over 
six  per  cent  for  all  cases  and  ages  ought  to  be  aspired  to.     All  the 

*  Consult  the  section  upon  this  subject  in  my  article,  "  Urinary  Calculus,"  in  the 
"International  Encyclopaedia  of  Surgery,"  vol.  vi. — Ketes. 


298  LiinoTOMY. 

large  operators  show  better  results — results  which  improve  the  more 
they  operate. 

Lithotomy  is  respectable  for  its  longevity  ;  but  it  is  idle  in  a  text- 
book of  the  present  day  to  discuss  the  unfavorable  o])inion  of  Ilip- 
])ocrates,  who  believed  that  wounds  of  the  bladder  were  deadly,  or  the 
barbarous  method  of  "cutting  on  the  gripe,"  the  ''api)aratus  minor," 
or  the  "  apparatus  major"  of  musty  antiquity.  Nor,  again,  does  space 
allow  a  detailed  description  of  the  many  cutting  operations  which  have 
been  proposed  and  successfully  performed  for  the  removal  of  stone 
from  the  bladder — operations  bearing  the  names  of  many  illustrious 
meu,  and  modilications  of  these  the  names  of  many  more,  to  whom  all 
honor  is  due.  Practically,  the  surgeon  requires  but  three  o])eratjons 
to  meet  the  necessities  of  all  cases,  and  these  three  only  will  be  de- 
scribed— they  are  the  lateral,  the  median,  and  the  high  operation  for 
stone.  For  the  statistics  I  have  collected  upon  lithotomy,  I  must  refer 
to  another  place.* 

Lateral  Litliotomij. — At  the  present  writing  it  seems  that  the  glory 
of  lateral  lithotomy  is  dying  away.  The  operation  is  only  required  for 
male  children,  where  the  operator  is  unwilling  to  employ  litholapaxy, 
possibly  for  a  few  foreign  bodies,  and  occasionally  wiien  bladder  drain- 
age is  required.  The  latter,  however,  may  be  as  well  or  better  at- 
tended to  by  median  incision  and  a  tube.  Large  stones  now  call  for 
the  high  operation,  and  vesical  and  prostatic  tumors  may  be  reached 
as  well  through  the  median  as  through  the  lateral  incision.  Multiple 
stone  is  suitable  for  lithotrity.  Eucysted  stoues  call  for  suprapubic 
cystotomy. 

Young  children  do  well  by  any  operation,  but  the  lateral  is  un- 
doubtedly the  best,  as  the  incision  is  not  liable  to  injure  the  seminal^ 
ducts,  and  a  free  outlet  is  afforded  for  the  extraction  of  the  stone.  If 
the  latter  is  quite  small,  the  median  operation  is  perhaps  as  good  ; 
but,  where  it  is  largo,  the  violence  done  in  dilating  the  vesical  neck  is 
objectionable.  It  is  exceedingly  rare  for  children  to  have  infiltration 
of  urine,  although  the  limits  of  the  prostate  are  undoubtedly  often 
surpassed  by  the  incision  in  the  lateral  operation.  Peritonitis  from 
violence  is  what  is  to  be  feared  in  children,  and  there  is  little  danger 
of  this  (even  with  large  stones)  from  the  lateral  operation.  The  median 
section,  however,  in  children  has  the  advantage  of  being  generally 
attended  by  less  haemorrhage,  and  is  useful  for  small  stones ;  the  older 
the  child,  the  less  objectionable  the  operation. 

The  lateral  operation  is  ascribed  to  Pierre  Franco,  of  Provence, 
about  the  middle  of  the  sixteenth  century,  and  claims  the  names  of 
Jacques  in  the  seventeenth  century,  and  Rau,  his  pupil,  in  the  eight- 
eenth.    It  was  popularized  and  practiced  with  great  success  in  Eng- 

*  Consult  the  section  upon  this  subject  in  my  article,  "  Urinary  Calculus,"  in  the 
'•  International  Encyclopaedia  of  Surgery,''  vol.  vi. — Keyes. 


INSTRUMENTS. 


299 


land,  by  Chcseldon,  in  the  last  century,  and  it  is  his  operation  whicli 
is  still  performed. 

Insti'uments  employed. — The  instruments  necessary  for  this  opera- 
tion are  the  searcher  (Fig.  09),  a  staff  of  proper  size  with  a  long  curve 
deeply  grooved  oh  its  convexity  (Fig.  86),  the  groove  encroaching  on 
the  right  lateral  aspect  of  the  staff  toward  the  point.     'J.''he  handle  of 
the  staff  should  be  broad,  heavy,  and  marked 
with  deep,  crossed  lines,  so  that  it  may  be  held 
firmly  with  greater  ease.     The  groove  should 
not  run  off  at  the  beak,  but  stop  abruptly,  leav- 
ing the  last  quarter  of  an  inch  blunt  and  round. 


I 


Fig. 


Fig.  87.      Fig.  88—^.      Fig.  88— S.       Fig.  89.         Fig.  90. 


The  scalpel  should  be  firm,  seven  or  eight  inches  long,  with  a  stout 
shank  and  solid  back,  the  blade  about  three  inches  long  (Fig.  87),  the 
cutting  edge  about  one  and  a  quarter  inch. 

Blizard's  probe-pointed  knife  (Fig,  88—^,  English  pattern),  long, 
straight,  with  a  stiff  back  and  (Fig.  88— .5,  American)  a  ribbed 
handle.  The  bkmt  gorget,  possibly  useful  where  the  patient  is  fat 
and  the  perinseum   deep   (Fig.  89).      The   scoop    (Fig.  90),  several 


300 


LITHOTOMY. 


forceps  of  different  sizes,  with  extremities  rougliened  in  the  inside  to 
hold  the  stone  firmly,  one  with  crossed  handles  (Fig.  91),  so  as  to  be 
opened  sufficiently  in  a  deep  perinanim  without  stretching  the  wound 
unduly  ;  another  with  its  blades  sharjily  curved  (Fig.  92),  so  as  to 
catch  stones  behind  the  pubcs  or  in  the  ''bas-fond."  The  heavy  in- 
struments, formerly  used  to  crush  stones  found  to  be  too  large  to  be 
extracted  through  the  lateral  incision,  are  no  longer  called  for,  such 
stones  being  properly  dealt  with  by  suprapubic  lithotomy.     I  think 


Fig.  91. 


Fio.  92. 


Fig.  93. 


Fig.  94. 


it  a  safe  rule  that,  if  two  of  the  diameters  of  a  stone  are  even  a  little 
over  an  inch  and  a  quarter  each,  the  patient  will  do  better  by  the  high 
operation  ;  and  it  is  quite  possible  that  the  future  may  narrow  the 
limit. 

A  metallic  tube,  one-third  inch  diameter  (Fig.  93),  with  an  open 
end  and  a  large  eye — furnished  with  an  obturator  for  easy  introduc- 
tion—through which  to  wash  out  debris.  Another  tube,  one-sixth 
inch  diameter,  provided  with  a  globular  head,  about  a  half-inch  diam- 
eter, having  large  holes  in  the  globular  head  pointing  backward  (Fig. 
94),  and  a  piece  of  rubber  tubing  on  its  proximal  extremity — this  to  be 
used  with  a  Davidson's  syringe  to  wash  out  debris.    A  shirted  cannula 


THE   OPERATION. 


301 


for  haemorrhage  (Fig.  95),  and  a  tenaculum  which  unscrews  at  the 
handle  (Fig.  96,  Keith's  tenaculum),  and  several  forciprcssure  for- 
ceps for  the  same  purpose  ;  Pritchard's  anklets  and  wristlets  (Fig.  97)  ; 
some  soft  rubber  and  other  catheters,  brandy,  hot  and  cold  water, 
sponges,  towels,  ligatures,  ether,  etc. 
These  make  up  the  necessary  list  of 
instruments.  At  least  five  assistants 
are  necessary  :  one  for  the  ether ;  one 
to  steady  each  knee  of  the  patient ; 
one — the  post  of  honor — to  hold  the 
staff ;  one  to  sponge  and  act  as  gen- 
eral assistant. 

The  Operation. — The  patient  is 
})repared  beforehand  as  for  any  other 
capital  operation,  and  in  addition  has 
the  perinaeum  shaved  and  receives  a 
full  enema  about  two  hours  before 
the  operation,  to  clear  the  rectum, 
after  which  he  abstains,  if  possible, 
from  again  passing  water.  He  should 
be  etherized  in  bed,  and  then  car- 
ried to  a  small,  firm  table,  and  com- 
fortably arranged  on  an  old  blanket. 
The  anklets  and  wristlets  are  adjusted  (or  the  hands  and  feet  bound 
together  with  bandage).  The  pelvis  is  now  drawn  to  the  lower  edge 
of  the  table,  facing  the  light,  a  piece  of  old  carpet  and  a  pan  with 

sawdust  placed  be- 


Fig.  95. 


Fig.  96. 


^^ 


neath  to  catch  the 
blood  and  urine. 
The  operator  passes 
the  staff,  feels  the 
stone  with  it,  and 
then  intrusts  it  to 
his  assistant  of 
honor,  and,  taking 
his  seat  on  a  low 
stool,  facing  the  pa- 
tient's pelvis,  with 
all  his  instruments 
systematically  ar- 
ranged within  easy 
reach  of  his  right  hand,  is  in  readiness  to  commence.  Should  the 
staff  fail  to  strike  the  stone,  it  may  be  withdrawn  and  the  searcher 
introduced.  Should  this  also  fail  to  detect  it,  after  a  careful  and  pro- 
longed sounding,  the  operation  should  be  deferred.     Some  of  the  best 


302 


LITHOTOMY. 


operators  have  been  deceived  in  their  diagnosis,  and  have  cut  patients 
in  wliom  no  stone  existed  ;  so  that  it  has  become  a  cardinal  rule  never 
to  cut  a  patient  in  whom  the  stone  can  not  be  felt  after  he  is  upon 
the  table.  The  sound  may  fail  to  detect  it,  if  it  lies  in  a  deep  ba.'i- 
f 0)1(1,  but  not  so  the  searcher. 

The  holder  of  the  staff  usually  satisfies  himself  that  the  sound 
strikes  the  stone.  It  is  not  essential  that  the  end  of  the  staff  should 
rest  against  the  stone.  As  long  as  it  is  certainly  in  the  bladder,  noth- 
ing more  is  required.  The  chief  assistant  stands  at  the  patient's  left, 
holds  the  staff  vertically,  steadily,  and  firmly  hooked  up  under  the 
symphysis,  with  its  long  curve  a  little  bellied  out  in  the  median  line 


Fio.  98  {T//o?npson). 


of  the  perinfeum,  and  keeps  the  integument  of  the  latter  taut  by  pull- 
ing the  scrotum  up  around  the  staff.  The  assistants  steady  the  knees, 
while  the  operator  impresses  his  mind  finally  with  the  shape  and  size 
of  the  long  outlet  of  the  pelvis  by  running  his  fingers  down  the  rami 
of  the  ischium,  touching  their  tuberosities,  feeling  the  symphysis  pubis 
and  the  coccyx.  The  surgeon  should  picture  to  himself  a  pelvis  lying 
before  him,  in  position,  denuded  of  soft  parts  (Fig.  98),  and  recall 
the  general  inverted  heart-shape  of  its  outlet  (Fig.  99). 

The  operator  now  introduces  the  left  index-finger  into  the  rectum, 
assures  himself  that  the  sound  enters  at  the  apex  of  the  prostate  and 
passes  centrally  through  its  canal,  and  that  the  rectum  is  empty  and 
collapsed.  Then,  withdrawing  his  finger,  he  searches,  with  the  thumb 
or  finger  of  his  left  hand  upon  the  raphe  of  the  perineum,  for  the 


THE   OrERATION. 


303 


groove  in  the  stafP,  which,  in  a  thin  person,  can  always  be  obscurely 
felt.  If  lie  can  not  feel  it,  he  takes  the  handle  of  the  staff  from  his 
assistant,  and,  by  depressing  it  several  times,  while  he  makes  i)ressure 
upon  the  perin83um,  he  satisfies  himself  of  the  position  of  the  groove, 
and  returns  the  staff  to  his  assistant. 

The  scalpel  is  now  entered  a  little  to  the  (patient's)  left  of  the 
raphe,  from  one  and  a  quarter  to  one  and  a  half  inch  in  front  of  the 
anus,  the  point  of  the  knife, 
guided  by  the  nail,  being  made 
to  enter  the  groove  of  the 
sound  and  open  the  urethra  at 
the  first  cut.  If  the  point 
enters  the  groove,  it  is  to  be 
pushed  along  for  a  quarter  to 
half  an  inch  —  if  it  fails  to 
strike  the  groove,  it  is  made 
to  pierce  more  or  less  deeply 
— and  then,  with  a  single  bold 
stroke,  the  first  incision  is 
made  laterally  to  the  right, 
about  three  and  a  half  inches 
long,  terminating  exactly  mid- 
way between  the  tuber  ischii 
and  the  anus.  The  scalpel  is 
again  entered  into  the  groove, 
and  the  urethra  amply  opened. 
The  practiced  lithotomist 
sometimes  uses  the  same  knife 
to  complete  the  operation,  but,  as  a  rule,  it  is  better,  at  this  stage,  to 
change  the  scalpel  for  Blizard's  knife.  The  probed  point  of  the  latter, 
following  the  guiding  index-finger,  is  passed  into  the  groove,  and  the 
surgeon  takes  the  handle  of  the  staff,  depresses  it  somewhat,  and,  fol- 
lowing the  groove,  pushes  his  knife  along  until  its  point  is  arrested  by 
the  abrupt  termination  of  the  groove  at  the  end  of  the  staff.  He  now 
increases  the  angle  between  his  knife  and  the  staff  by  depressing  the 
handle  of  the  former,  and,  remembering  the  position  and  shape  of  the 
prostate,  he  cuts  his  way  out,  his  incision  through  the  prostate  being 
at  about  an  angle  of  30°  with  the  horizon,  his  external  incision  at  an 
angle  of  about  50°  A  glance  at  Fig.  99  shows  at  once  the  relation 
between  the  incisions  and  their  relation  to  the  prostate  and  anus.  A 
gush  of  urine  usually  follows  this  incision.  If  the  external  incision 
has  not  been  bold  enough,  it  may  now  be  enlarged  with  a  few  strokes 
of  the  scalpel. 

If  the  above  directions  are  followed,  there  is  little  danger  of  that 
disagreeable  accident,  cutting  into  the  rectum. 


Fig.  99  {Thompson). 


304  LITHOTOMY. 

Instead  of  dividing  tlic  prostate  with  tlic  knife,  numerous  inge- 
nious lithotomes  have  been  devised,  which  incise  to  a  greater  or  less 
distance,  according  to  a  previously  arranged  gauge,  or  can  only  cut  to 
a  limited  extent,  as  in  the  bisector  of  Wood,  and  that  of  Post,  of  New 
York.  The  single-cutting  ''lithotome  cache,"  of  Frere  C6me,  and 
the  double  instrument  of  Dupuytren,  with  their  many  modilications, 
of  which  that  of  Briggs,  of  Nashville,  is  simple  and  eflficient,  all  of 
these  are  undoubtedly  good  ;  but  the  surgeon  should  learn  early  to 
depend  as  much  as  possible  upon  his  brains  and  his  lingers,  and  as 
little  as  possible  upon  instruments,  if  he  would  acquire  self-confidence, 
without  which  any  operation  for  stone  is  unsurgical.  Hence  it  is 
advisable  for  the  young  surgeon  to  familiarize  himself  with  the  use 
of  the  scalpel  aud  Blizard's  knife,  and  to  do  all  his  cutting  v\ith  these 
instruments,  or  even  with  the  scalpel  alone,  remembering  that  the 
greatest  average  lateral  dimensions  of  the  adult  prostate  are  only  one 
and  a  half  inch,  and  that  a  depth  of  incision  one  half,  or  at  most  five 
eighths  of  an  inch,  into  one  side  of  the  prostate  should  be  a  limit 
never  surpassed — dilatation  will  do  the  rest. 

Having  now  completed  the  incisions,  the  index-finger  of  the  left 
hand  should  be  gently  introduced  into  the  bladder,  and  the  sound 
withdrawn.  The  finger  usually  comes  at  once  in  contact  with  the 
stone.  The  bladder's  neck  is  now  to  be  dilated  slowly  but  thoroughly 
with  the  finger — if  the  perinaeum  be  deep  with  fat,  with  the  blunt 
gorget,  carried  in  along  the  groove  of  the  staff.  If  the  stone  has  been 
previously  measured,  and  is  less  than  one  inch  in  diameter,  or  if  there 
are  many  small  stones,  the  surgeon  should  proceed  to  extract  at  once. 
If,  however,  the  stone  is  above  one  inch  in  diameter,  Blizard's  knife 
should  be  reintroduced  on  the  finger,  and  the  prostate  cut  on  the  (pa- 
tient's) right  side.  After  being  satisfied  that  the  neck  of  the  bladder 
is  nicked,  the  prostate  sufficiently  cut,  the  whole  wound  dilated  and 
dilatable,  the  forceps  is  passed  into  the  bladder  as  the  finger  is  with- 
drawn. One  blade  is  depressed  into  the  floor  of  the  bladder,  the  other 
is  widely  opened,  and  usually,  on  closing  them,  the  stone  will  be  caught. 
Failing  in  this,  search  laterally  and  further  back  in  the  bladder  must 
be  made,  the  direction  of  the  blades  being  changed,  until  the  stone 
is  seized.  In  cases  of  deep  perinaeum  the  small  end  of  the  scoop  is 
introduced  until  it  touches  a  stone,  and  then  the  forceps  is  followed 
along  upon  the  scoop  as  a  guide  until  it  enters  the  bladder  and  strikes 
the  stone.  It  should  never  be  forgotten  during  these  manoeuvres  that 
the  bladder,  usually  already  much  inflamed,  is  often  nearly  empty, 
clasping  the  stone,  and  that  any  roughness  or  force  may  inflict  serious 
(perhaps  fatal)  injury  upon  the  patient.  The  utmost  gentleness,  de- 
liberation, and  care  are  necessary  during  this  stage  of  the  operation  ; 
indeed,  the  catching  and  skillful  extraction  of  the  stone  is  often  a 
more  delicate  proceeding  than  any  other  part  of  the  operation. 


THE   OPERATION.  305 

If  it  is  found  that  the  stone  lius  been  seized  in  a  faulty  diameter, 
it  should  be  dropped  or  pushed  out  of  the  jaws  of  the  instrument, 
IDerhaps  rolled  over  with  the  finger,  and  another  attempt  made  to 
catch  it  correctly.  Extraction  should  be  slow,  the  traction  being 
made  iu  the  line  of  the  external  incision,  downward  and  outward. 
Lateral  motions  should  be  given  to  the  forceps  during  extraction,  the 
force  being  about  two  thirds  lateral,  one  third  extractive.  It  must  be 
remembered  that  the  most  fatal  source  of  danger  in  lithotomy  is 
bruising  and  lacerating  the  neck  of  the  bladder  in  forcible  efforts  at 
removing  the  stone ;  and  if,  after  the  exercise  of  a  sufficient  amount 
of  force — the  amount  to  be  learned  only  by  experience — the  stone  will 
not  engage  in  the  outlet  of  the  bladder,  it  is  far  more  brilliant  mor- 
ally, and  better  surgery,  to  perform  the  high  operation  for  the  removal 
of  the  stone,  and  leave  the  perineal  opening  for  drainage,  rather  than 
to  put  the  patient's  life  in  danger  by  insisting  upon  extracting  the 
stone  according  to  the  plan  first  conceived. 

After  one  stone  has  been  extracted,  if  it  is  found  to  be  smoothly 
rounded  and  presenting  no  facets,  there  is  probably  no  other  present ; 
if  it  has  facets,  the  reverse  is  almost,  if  not  quite,  certain  to  be  the 
case.  Phosphatic  calculi  are  often  multiple,  uric  acid  less  commonly 
so,  oxalate  of  lime  often  single.  In  any  case,  after  extracting  one  stone, 
careful  search  should  be  made  for  another  with  the  searcher  and  the 
small  end  of  the  scoop  through  the  perineal  wound.  Should  any  stone 
break  during  extraction,  and  in  those  rare  cases  where  a  quantity  of 
cUhris  is  found  in  the  bladder,  partly  adherent  to  ulcerated  patches  of 
mucous  membrane,  the  large  end  of  the  scoop  is  to  be  used  to  spoon 
out  the  earthy  matter,  and  then  copious  injections  of  tepid  water  are 
to  be  thrown  into  the  bladder  with  the  Davidson's  syringe  through 
the  large  tube  (Fig.  93),  or  the  bulbous-headed  irrigator  (Fig.  94), 
until  the  bladder  is  clean. 

When  the  stone  is  found  to  be  encysted,  or  fixed  in  position  by 
some  faulty  contraction  of  the  bladder  behind  the  pubis,  or  in  the 
fundus,  the  dexterity  of  the  operator  may  be  taxed  to  seize  it  with  the 
forceps,  but  intelligent  efforts,  gently  and  carefully  prolonged,  will 
usually  overcome  the  difficulty.  If  the  stone  is  deeply  encysted,  it 
may  be  impossible  to  liberate  it.  The  neck  of  the  cyst  may  be  nicked 
in  several  places,  efEorts  made  to  gnaw  off  any  projecting  jDortions  of 
stone,  and  gradually  to  insinuate  the  narrow  blades  of  a  small  curved 
forceps  to  extract  it.  Each  case  must  be  coolly  studied  out  at  the 
time  ;  no  definite  rules,  covering  all  contingencies,  can  be  given.  The 
high  operation  may  be  required. 

Hcemorrhage  during  the  operation  is  rarely  profuse.  The  lower 
part  of  the  bulb  is  generally  cut  into.  Spurting-points  should  be  tied 
as  they  occur,  or  twisted.  When  the  bleeding-point  is  deep  in  the 
wound  it  is  difficult  to  tie,  and  removing  the  tenaculum  may  loosen 

20 


306  LITHOTOMY. 

the  ligature.  To  meet  sucli  an  emergency,  it  is  jn'opcr  to  tie  in  a 
tenaculum,  and  for  this  purpose  Keith's  idea  (Fig.  96),  of  having 
a  tenaculum  from  which  the  handle  may  be  unscrewed,  is  a  good  one. 
Thompson  says,  "  I  believe  I  have  saved  a  life  on  one  or  two  occasions 
by  tpug  in  a  tenaculum."  In  one  instance  the  instrument  was  left 
in  ten  days,  when  it  came  away  spontaneously.  The  forcipressure 
forceps  answers  the  same  purpose  even  better  than  the  tenaculum. 

Digital  pressure  for  several  hours  of  tlie  pudic  artery  against  the 
ischio-pubic  ramus  may  serve  to  arrest  arterial  luvmorrhage,  otherwise 
runcontrollable.  Ice  and  iced-water  irrigation  is  an  adjuvant  which 
may  be  resorted  to.  Even  the  pudic  artery  may  be  tied  by  taking  a 
short,  stout,  curved  needle  with  a  holder,  introducing  it  through  the 
soft  parts  cldse  to  the  anterior  border  of  the  bone,  bringing  it  out 
about  three  quarters  of  an  inch  deeper,  and  then  firmly  tying  the  liga- 
ture which  it  carried. 

Venous  Jicemorrhage,  unless  profuse,  may  be  disregarded  ;  if  severe, 
it  calls  for  plugging  of  the  wound.  This  is  effected  with  the  "shirted 
cannula"  (Fig.  95),  or  any  female  catheter  will  do,  with  a  sufficiently 
large  square  piece  of  muslin  having  a  hole  in  its  center,  tied  firmly 
around  the  tube,  at  about  an  inch  from  the  extremity  which  enters  tlie 
bladder — or  even  a  soft  sponge  perforated  by  a  female  catheter.  This 
is  introduced  deeply  into  the  wound,  and  the  flaring  sack  around  the 
central  tube  is  closely  packed  with  small  pellets  of  lint,  sponge,  or 
oakum,  the  whole  kept  in  place  with  a  snugly-applied  T-bandage. 

Generally  all  oozing  may  be  arrested  by  simply  bringing  the 
thighs  together,  and  bandaging  the  knees,  thighs,  and  ankles.  The 
mutual  pressure  of  the  two  surfaces  of  the  wound  answers  admirably 
well. 

After-treatment. — If  the  patient  seems  to  be  sinking  during  or 
immediately  after  the  operation,  before  he  has  emerged  from  his  an- 
aesthesia, and,  consequently,  when  he  can  not  swallow,  an  excellent 
means  of  stimulating  him  consists  in  passing  through  one  nostril  a 
soft  French  olivary  catheter  (about  size  15  F.)  past  the  pharynx  into  the 
oesophagus,  and  throwing  into  his  stomach  small  doses  of  brandy  with 
a  syringe.  The  catheter  may  be  left  m  during  the  whole  operation, 
and  does  not  interfere  with  the  administration  of  the  ether.  One  cau- 
tion is  necessary  :  It  is  prudent,  before  injecting  the  brandy,  to  notice 
whether  any  air  comes  out  of  the  catheter  during  expiration,  as  the 
instrument  may  possibly  have  passed  into  the  trachea  ;  if  time  allows 
the  slower  absorption,  injection  into  the  rectum  may  be  substituted. 
The  patient  is  placed  upon  a  mattress,  with  the  hips  upon  a  rubber 
cloth  and  folded  compress,  and  napkins  placed  under  him,  which,  by 
being  frequently  changed,  indicate  the  amount  of  ha?morrhage.  Urine 
passes  freely  at  first  through  the  wound,  always  more  or  less  tinged 
with  blood.     The  wound  swells  so  much  sometimes,  before  suppura- 


LATERAL   OPERATION   IN   CUILDREN.  307 

fcion  is  established,  that  part  of  the  urine  on  the  second  day  flows 
throuo-h  the  meatus,  or,  indeed,  retention  may  come  on.  The  latter 
is  relicA'ed  by  gently  introducing  a  female  catheter  or  a  finger  through 
the  wound. 

Opium  may  be  given  from  the  first  to  control  pain,  to  be  pushed 
judiciously  on  the  appearance  of  any  evidence  of  peritonitis.  Diet 
should  be  light,  but  sustaining.  If  the  patient  has  been  addicted  to 
stimulants,  he  should  not  be  deiirived  of  them  in  moderation,  and  the 
same  is  true  of  opium.* 

The  wound  usually  closes  by  granulation.  As  suppuration  comes 
on,  there  is  not  infrequently  a  slight  chill,  with  (surgical)  fever,  but 
the  patient  is,  on  the  whole,  comfortable,  and  delighted  to  be  free 
from  his  old  pain.  Sometimes  the  wound  becomes  coated  with  urin- 
ary salts.  This  is  prevented  by  frequent  sjrringing  with  warm  water, 
to  which  a  few  drops  of  dilute  nitric  acid  have  been  added.  (Certain 
complications  are  described  after  the  median  operation.) 

liATERAIi    OPERATION    IN    CHILDBEN. 

In  children  the  staff  is  smaller,  with  a  shorter,  sharper  curve,  as 
the  bladder  lies  high  ;  hence,  the  staff  must  be  hooked  well  behind  the 
symphysis.  The  incisions  are  made  in  the  same  manner  as  in  the 
adult.  The  lower  end  of  the  rectum  is  often  prolapsed  in  children 
with  stone  ;  this  is  reduced  before  the  first  incision,  and  kept  in  with 
the  finger.  There  is  little  danger  of  cutting  it,  with  the  exercise  of 
any  ordinary  care.  The  incision  at  the  neck  of  the  bladder  usually,  if 
not  always,  cuts  entirely  through  the  limits  of  the  prostate,  which  is 
very  minute  before  puberty,  but  it  is  a  matter  of  no  importance.  In- 
filtration of  urine  does  not  occur  after  it.  There  is  much  more  danger 
in  making  too  small  an  incision,  and  lacerating  and  bruising  the  parts 
during  extraction  of  the  stone.  The  lateral  incision  of  the  prostate 
avoids  the  seminal  ducts.  There  is  danger  in  children,  if  the  mem- 
branous urethra  and  bladder-neck  have  not  been  sufficiently  cut,  that 
an  attempt  to  introduce  the  finger  and  dilate  the  latter  may  require 
so  much  force  that  the  membranous  urethra  is  torn  across  and  the 
bladder  pushed  before  the  advancing  finger.      The  mention  of  this 

*  A  patient,  past  middle  life,  from  whom  I  removed,  by  the  lateral  operation,  eight 
phosphatic  stones  weighing  collectively  two  ounces  three  hundred  and  twenty  grains,  had 
been  so  tortured  by  pain  during  a  number  of  years  by  his  malady,  which  had  been  unrec- 
ognized, that  he  acquired  the  habit  of  opium-eating.  His  daily  dose  was  seventy  grains 
of  opium  and  two  or  three  ounces  of  laudanum.  After  the  operation  his  pain  ceased, 
and  his  opium  was  rapidly  cut  do\vn  to  a  very  small  daily  dose.  But,  although  he  did 
well  in  every  other  respect,  his  wound  absolutely  refused  to  granulate  during  several 
weeks.  On  this  account  he  was  allowed  to  resume  his  large  doses  of  opium,  and,  when 
he  reached  nearly  his  habitual  quantity,  his  wound  rapidly  granulated  and  went  on  to 
speedy  union ;  after  which  his  opium  was  again  reduced. — Keyes. 


308  LlTllOTUMV. 

accident  will  insure  against  its  occurrence.  Another  caution  must  be 
given,  namely,  that  the  first  opening  into  the  urethra  should  be  suffi- 
ciently ample  to  insure  its  easy  discovery  upon  search,  so  as  to  avoid 
the  necessity  of  making  several  openings  at  different  angles  in  a  small 
urethra — an  accident  which  might  be  followed  by  stricture.  All  care 
is  necessary  in  extracting  the  stone.  IIa3morrhage  in  young  subjects 
is  very  devitalizing.     All  the  blood  that  is  possible  should  be  saved. 

Children  cut  by  the  lateral  operation  rally  with  surprising  rapidity. 
Every  surgeon  of  large  experience  recounts  cases  where,  on  visiting  the 
child  twenty-four  hours  after  the  operation,  he  finds  him  up  and  play- 
ing about  the  room — possibly  out  of  doors  with  his  companions.  Ac- 
cidents, however,  do  occasionally  occur  with  the  young,  and  due  care 
should  be  exercised  in  the  after-treatment  to  meet  all  symptoms  ap- 
propriately— especially  any  indication  of  peritonitis,  a  complication  of 
lithotomy  proportionally  much  more  common  in  childhood  than  in 
later  life. 

THE    MEDIAN    OPERATION. 

The  median  is  known  classically  as  the  Marian  operation,  devised 
in  the  sixteenth  century,  and  afterward  largely  adopted  and  improved 
in  Italy.  Allarton  has  been  its  apostle  in  England,  and  the  modern 
ojieration  is  known  by  his  name.  In  this  country  j\Iarkoe  first  brought 
it  into  particular  prominence,  and  the  names  of  Little  and  Walter  are 
also  connected  with  it.  Each  of  these  three  surgeons  has  enjoyed  re- 
markable success  with  this  operation. 

The  median  operation  is  suitable  for  very  small  stones  in  children 
where  litholapaxy  is  not  considered  suitable,  for  small  stone  in  adults 
when  the  bladder  requires  subsequent  drainage  through  a  tube,  and 
for  cases  in  which  there  is  prostatic  or  other  tumor  to  be  dealt  with 
by  the  same  operation. 

Instruments  kequired. — The  only  instruments  necessary,  differ- 
ing from  those  employed  in  the  lateral  oi^eration,  are  three  :  a  staff, 
director,  and  knife.  The  staff,  of  appropriate  size,  has  a  central 
groove,  with  a  broad  flare.  Markoe  (Fig.  100)  and  Little  (Fig.  101) 
have  each  adopted  a  staff.  The  groove  of  the  latter  is  deeper,  furnish- 
ing, its  author  believes,  greater  convenience  and  certainty  in  dividing 
the  membranous  urethra.  A  ball-pointed  probe,  or  a  dh'ector,  known 
as  Little's  (Fig.  102),  is  generally  employed,  and  a  straight,  stout, 
sharp-pointed  bistoury,  generally  made  to  cut  slightly  uj)on  the  back 
for  a  short  distance  from  the  point. 

Operation. — The  patient  bound  in  the  lithotomy  position,  and  the 
staff  introduced  in  contact  with  the  stone,  the  operator  passes  the 
index-finger  of  the  left  hand  into  the  rectum,  familiarizes  himself  with 
the  feel  of  the  parts,  and  accurately  locates  the  apex  of  the  prostate, 
just  where  the  staff  enters  it.     He  now  transfixes  the  perinaeum  about 


MEDIAN   OrERATION. 


309 


half  an  inch  above  the  anus,  with  the  sharp-pointed  bistoury,  the  cut- 
ting-edge upward,  entering  the  point  of  the  same,  guided  by  his  finger 
in  the  rectum,  into  the  central  groove  of  the  staff,  at  the  apex  of  the 
prostate.  The  double-edged  point  is  now  advanced  very  slightly  into 
the  groove,  so  as  certainly  to  enter  the  urethra, 
and  barely  nick  the  apex  of  the  prostate.  Finally, 
the  knife  is  made  to  cut  forward  and  divide  the 

membranous  urethra 
within,  and,  the  han- 
dle being  elevated  in 
the  vertical  plane,  the 
blade  is  swept  around 
so  as  (theoretically  at 
least)    to    avoid    the 


Fig.  100. 


Fia.  101. 


Fig.  102. 


bulb,  and  cut  its  way  out  along  the  raphe,  the  external  incision  being 
from  one  and  a  quarter  to  one  and  a  half  inch  long.  Thompson  pre- 
fers making  the  incision  from  without  centrally  inward.  The  director 
is  now  passed  along  the  staff  into  the  bladder,  and,  these  two  being 
separated  in  an  angular  way,  the  neck  of  the  bladder  is  dilated,  some 
urine  flowing  out  during  the  process.  The  staff  is  now  withdrawn, 
and  a  finger  introduced  through  the  wound,  with  which  the  dilata- 
tion is  completed,  without  cutting  the  prostate  or  the  neck  of  the 
bladder.  The  stone — necessarily  not  very  large — is  withdrawn,  as  in 
lateral  lithotomy,  and  the  general  after-care  of  the  patient  is  the  same. 


310  LlTnOTOMY. 

The  operation  yields  excellent  results;  the  patient  sometimes  re- 
tains control  over  his  urine  from  the  lirt^t.  The  wound  usually  heals 
rajtidly.  Tlio  objections  to  the  operation  are  :  its  oeneral  inapplica- 
bility except  for  stones  which  lithotrity  is  more  ca})able  of  managing, 
and  the  temptation  to  use  violence  during  the  extraction  of  a  too  large 
stone.  ^Vhere  ratiier  largo  stones  are  extraced  by  this  method,  incon- 
tinence, sometimes  lasting  several  years,  may  occasionally  ensue,  and 
it  is  claimed  (Toevan  *)  sterility. 

COMPLICATIONS   OF   LITHOTOMY. 

Shock,  exhaustion,  septicemia,  pyannia,  erysipelas,  possibly  tetanus, 
may  be  encountered  after  lithotomy,  and  recpiire  to  be  met  according 
to  general  surgical  principles.  Unusual  complications  in  the  way  of 
luvmorrhage,  besides  those  already  alluded  to,  may  occur  in  connec- 
tion with  the  ha?morrliagic  diathesis,  or  in  those  rare  cases  of  irregular 
arterial  distribution  where  the  main  pudic  trunk  is  defective,  and  its 
place  supplied  by  an  accessory  pudic  lying  close  along  the  border  of 
the  i)rostate,  or  where  the  artery  of  the  bulb  is  given  off  farther  back 
than  usual,  or  the  main  artery  of  the  prostate  enters  the  gland  in  a 
position  exposing  it  to  injury.  These  complications  are  met  by- 
especial  attention  to  the  means  of  arresting  heemorrhage,  already  de- 
tailed in  describing  the  lateral  operation.  Secondary  hemorrhage 
sometimes  comes  on  several  days  after  the  operation.  Thompson  has 
had  four  cases,  two  of  which  were  fatal.  The  wound  is  small ;  liga- 
ture can  rarely  be  applied.  Thompson  advises  perchloride  of  iron, 
carried  in  upon  lint  at  the  end  of  a  probe,  or  the  actual  cautery. 
Perchloride  of  iron  might  be  injected.  South  reports  arrest  of  the 
hcemorrhage  in  several  cases  by  pressure  on  the  pudic  artery,  long 
continued. 

Peritonitis,  more  common  in  the  child,  may  complicate  the  opera- 
tion in  the  adult.  The  rectum  may  be  Avounded,  or  the  perineal 
wound  may  inflame  from  mechanical  injury  or  diathetic  cause,  result- 
ing possibly  in  sloughing  of  a  part  of  the  rectum.  Fistula  may  be  left 
behind,  retention  may  follow  the  operation,  or  temporary  or  even  per- 
manent incontinence,  and  even  occasionally  sterility,  from  obliteration 
of  the  ejaculatory  ducts  by  section  or  subsequent  inflammation. 
Epididymitis  may  come  on,  as  after  any  operation  involving  the  pros- 
tate, bystitis  may  run  high  from  injury  to  the  bladder  during  ex- 
traction of  the  stone  ;  chronic  disease  in  the  kidney  may  be  kindled 
into  an  acute  state.  All  of  these  complications  are  to  be  met  accord- 
ing to  suggestions  already  laid  down  in  other  parts  of  this  treatise. 

By  far  the  most  common  complications  after  operation  are  inflam- 
mation of  the  parts  around  the  bladder  neck  (cellulitis),  and  infiltra- 

*  "Lancet,"  April  C,  ISIS,  p.  498. 


INSTRUMENTS.  311 

tion,  both  due  to  tlio  same  cause — mechanical  violence  in  extracting 
too  large  a  stone,  or  jagged  fragments,  through  an  insulTicient  open- 
ing. Lack  of  vitality  in  the  patient  undoubtedly  conduces  to  these 
results,  and  infiltration  may  be  due  to  an  incision  surpassing  the  limits 
of  the  fibrous  capsule  of  the  prostate.  But  that  infiltration  is  more 
often  dependent  upon  tearing  and  laceration  during  the  extraction  of 
large  stones,  is  advanced  by  Thompson,  supported  by  the  fact  that  in 
children  infiltration  is  rai'e,  although  the  incision,  as  a  rule,  in  the 
lateral  operation,  generally  surpasses  the  limits  of  the  prostate,  and 
notwithstanding  the  fact  that  in  children  the  cellular  tissue  is  particu- 
larly loose. 

Relapse  of  stone  is  liable  to  occur  if  any  fragment  is  left  in  the 
bladder,  and  no  part  of  the  ojDcration  requires  more  care  than  the 
thorough  evacuation  of  debris,  in  any  case  where  a  stone  has  been, 
broken  intentionally,  or  accidentally  crushed  during  extraction.  If, 
after  healing  of  the  wound,  any  symptoms  referable  to  stone  should 
continue,  a  careful  search  may  detect  the  fragment,  while  yet  small, 
and  furnish  an  opportunity  for  the  use  of  the  lithotrite. 

CASE   OF   INSTKUHtENTS   FOR   STONE. 

The  following  instruments  might  be  grouped  into  one  case.     They 
are  sufficient  to  meet  all  the  ordinary  requirements  of  stone  : 
Thompson's  searcher. 
Two  lithotrites,  heavy  and  light. 
Bigelow's  washing  bottle  and  assortment  of  tubes. 
Urethral  forceps. 

Lateral  lithotomy  staff,  small  and  large. 
Median  lithotomy  staff. 
Lithotomy  scalpel. 

Straight,  sharp-pointed,  narrow,  stiff-backed  bistoury. 
Blizard's  knife. 
Blunt  gorget. 
Little's  director. 
Scoop. 

Lithotomy  forceps,  with  crossed  handles. 
Lithotomy  forceps,  with  curved  blades. 
Crushing  forceps,  with  extra  piece. 
Tube  with  globular  head,  for  washing  bladder. 
Shir  ted  cannula. 
Keith's  tenaculum. 
Several  forcipressure  forceps. 


s# 


312  SUPRATUBIC  LirnOTOMY. 


CHAPTEE    XYIir. 
SUPRAPUBIC   LITHOTOMY. 

Cases  Suitable  for  the  Operation.— Operative  Method.— After-treatment. 

This  operation,  designed  in  15G1  by  Franco,  after  passing  throngh 
a  varying  history,  is  in  onr  day,  notably  on  account  of  the  admirable 
modification  lent  to  it  by  Petersen,  again  rising  in  prominence,  so  much 
so  that  its  ardent  admirers  even  claim  its  applicability  to  all  cases, 
young  and  old  ;  to  all  stones,  large  and  small.  The  folly  of  such  a 
proposition  seems  to  me  self-evident.  When  litholapaxy  gives  an 
average  mortality  at  all  ages  of  less  than  six  per  cent — lateral  lithotomy 
in  children  below  puberty  being  almost  a  minor  operation,  for  death 
is  phenomenally  rare — how  can  it  be  proposed  to  substitute  the  high 
operation  until  it  has  shown  better  results  than  had  been  reached  in 
1885,  when  the  mortality  w^as about  twenty-f5ve  percent?*  Doubtless 
it  is  much  better  now.  My  own  early  experience  with  the  operation 
was  unfortunate,  but  in  the  winter  of  1886-'7  I  operated  three  times 
in  severe  cases,  and  all  recovered,!  and  since  that  date  my  results 
have  left  nothing  to  desire. 

In  my  opinion  the  operation  is  suitable  for  all  large  stones,  that  is, 
those  which  have  two  diameters  greater  than  one  and  a  half  inch,  or 
it  may  be  safer  to  make  the  limit  even  smaller  in  the  future,  for  the 
mortiility  after  lateral  lithotomy  increases  rapidly  with  the  size  of  the 
stone — not  so  in  the  high  operation.  Most  stones,  however,  even  of 
these  diminsions,  are  suitable  for  litholaj^axy ;  therefore  it  must  be 
added  that  only  very  large  stones,  and  moderately  large  ones  which 
can  not  be  crushed,  are  to  be  removed  by  the  high  operation.  Encysted 
stones,  stones  complicating  tumor,  and  foreign  bodies — tliis  list,  it  will 
be  seen,  takes  in  nearly  everything  except  the  stones  which  litholapaxy 
can  cojje  with. 

Instruments  required. — The  only  special  instrument  required  for 
the  high  operation  is  the  rectal  colpeurynter  of  Petersen  (Fig.  103), 
a  rubber  bag,  capable,  when  distended,  of  holding  about  a  pint.  The 
bags  commonly  used  are  those  of  Guyon,  or  a  pear-shaped  bag  bearing 
Thompson's  name.  Among  ordinary  instruments  required  may  be 
cited  scalpel,  scissors,  curved  needles  and  holder,  curved  sharp  bis- 
toury, sponges  on  holders,  lithptomy  forceps,  soft  catheter,  and  forci- 
pressure  forceps. 

*  Art.  "  Urinary  Calculu3,"  "  International  Encyclopaedia  of  Surgery,"  vol.  vi,  p.  200. 
f  "Journal  of  Cutaneous  and  Genito-Urinary  Diseases,"  July,  IBS'?,  p.  242. 


THE   OPERATION. 


313 


The  Operation. — The  hair  is  shaved  from  the  pubis  and  j)cri- 
nseum,  and  the  patient  prepared  as  for  other  operations  upon  the 
bladder.  The  abdomen  is  washed  with  an  antiseptic  solution  (one  in 
a  thousand  of  bichloride  of  mercury).  A  soft  catheter  is  passed,  and 
throu,"-h  it  the  bladder  is  washed  with  a  four-pcr-cent  boric-acid 
solution,  hot,  or  a 
warm  solution  of 
borax  in  water,  un- 
til the  wash  returns 
clear. 

The  colpeuryn- 
ter  is  now  passed 
into  the  rectum.  I 
have  never  thrown 
in  more  than  twelve 
ounces,  and  I  believe 
this  to  be  a  safe  limit 
and  an  ample  one. 
I  prefer  less  rather 
than  more. 

Now  the  blad- 
der is  distended  by 
throwing  in  a  berat- 
ed solution.  I  have 
rarely  used  more 
than  ten  ounces,  but 
the  amount  to  inject 

may  be  varied  according  to  the  known  capacity  of  the  bladder,  or  until 
(in  a  thin  person)  the  outline  of  the  viscus  appears  above  the  pubis. 

It  should  never  be  forgotten  that  the  rectum  has  been  lacerated  bj 
overdistention  of  the  colpeurynter,  and  the  bladder  ruptured  in  the 
hands  of  most  competent  surgeons  (Monod,  Cheselden,  Verneuil),  and 
an  error  should  be  made,  if  any,  on  the  side  of  safety. 

Now  a  central  incision  about  three  inches  long  is  made  in  the 
middle  line,  terminating  at  the  pubic  symphysis.  The  superficial  fas- 
cia is  cut  through  with  the  skin,  the  deep  fascia  more  carefully.  The 
sulcus  between  the  recti  muscles  is  sought,  but,  if  not  easily  found,  a 
central  incision  is  made  cleanly  through  the  muscle  parallel  to  its 
fibers.  No  separation  of  the  muscles  should  be  made  except  what  is 
absolutely  necessary,  for  such  separations  favor  the  possibility  of  subse- 
quent infiltration.  Particularly  is  it  desirable  not  to  poke  about  with 
the  fingers  or  instruments  in  the  prevesical  space  behind  the  symphy- 
sis. This  is  the  most  dangerous  area  after  the  operation,  the  one  in 
which  pus  is  most  likely  to  form  and  be  a  source  of  possible  compli- 
cation. 


Fig.  103. 


314  SUPRAPUBIC  LITHOTOMY. 

After  getting  fairly  through  the  muscles,  a  thin  fascia  is  observed 
with  yellow  fat  beneath  it.  This  fascia  is  freely  tlivitled  in  the  middle 
line,  then  the  pulp  of  the  finger  is  placed  between  the  yellow  layer 
of  fat  and  the  symphysis,  and  the  fat  is  rolled  upward  toward  the 
upper  angle  "of  the  incision.  This  layer  of  yellow  fat  contains  the 
poritonanim.  Guyon's  niancBuvre  of  rolling  it  up  is  admirable.  I  have 
practiced  it  a  number  of  times,  and  I  have  never  seen  the  peritonasum 
in  any  operation  when  I  have  done  the  cutting,  cxccjjt  in  two  in- 
stances in  which  the  bladder  was  cancerous  and  the  i)eritona?um  ad- 
herent. 

If  the  peritoneum  is  opened  it  is  not  an  important  accident.  The 
wound  is  antiseptically  washed  and  sutured  with  tine  catgut,  being 
kept  out  of  the  way  in  the  upper  angle  of  the  incision  during  the  re- 
mainder of  the  operation. 

After  the  yellow  fat  has  been  rolled  up  the  bladder  is  exposed,  often 
covered  with  distended  veins.  With  short-curved  needles  in  a  holder, 
a  portion  of  the  bladder  is  taken  up  in  a  broad  loop  on  either  side,  the 
silk  knotted  in  long  loops,  and  these  are  used  to  hold  up  the  sides  of 
the  incision  into  the  bladder.  If  the  veins  are  small  they  may  be 
disregarded,  and  the  bladder  boldly  cut  into  between  the  ligature  loops. 
If  haemorrhage  is  much  dreaded  they  may  be  secured  before  the  bladder 
is  opened  by  passing  beneath  them  a  piece  of  fine  catgut  with  a  short, 
sharply-curved  needle,  and  tying  the  gut.  A  number  of  such  liga- 
tures may  be  employed,  and  the  loss  of  blood  be  reduced  to  a  minimum. 

Xow  the  bladder  is  freely  opened,  the  finger  enters,  finds  the  stone, 
and  rolls  it  into  a  suitable  position.  With  a  forceps  it  is  easy  to  seize 
and  extract  any  stone  or  foreign  body,  and  to  inspect  the  inside  of  the 
bladder  as  well  by  using  a  reflector,  an  electric  light,  or  tlie  Trendelen- 
burg position — that  is,  having  the  patient's  knees  bent  over  the  shoul- 
ders of  a  tall  man,  who  lifts  the  pelvis  high,  leaving  the  shoulders  low. 
The  intestines  suck  back  the  upper  wall  of  the  bladder,  and  atmos- 
pheric pressure  distends  its  cavity  so  that  the  orifice  of  the  urethra  and 
the  orifice  of  each  ureter  can  be  plainly  seen,  and  the  jets  of  the  urine 
as  they  spirt  from  the  latter,  upon  manipulating  the  kidney. 

Shall  the  bladder-wound  be  sewed  up  ?  I  formerly  thought  and 
said  "No  to  this  question,  but  it  was  upon  insufficient  data.  I  have  now 
sewed  up  the  bladder  by  using  catgut,  a  continuous  suture,  and  not 
passing  the  suture  through  the  mucous  membrane,  but  only  partly 
through  the  muscular  coats.  I  have  used  this  method  in  three  con- 
secutive cases,  and  only  had  a  slight  leakage  from  the  lower  angle  of 
the  wound  for  two  or  three  days  in  two  of  the  cases  ;  the  third  united 
throughout  by  first  intention.  I  leave  the  external  wound  open  in 
doubtful  cases,  where  there  is  considerable  dread  of  leakage,  but  ordi- 
narily close  it,  passing  a  rubber  drainage-tube  well  into  the  prevesical 
space,  and  a  short  drainage-tube  between  the  cutaneous  lips  above. 


THE  OPERATION.  3I5 

When  the  external  wound  is  united,  I  include  skin,  fuscia,  and  recti 
muscles  on  both  sides  in  the  sutures,  putting  in  a  few  superficial  ones 
if  required.     Dress  antiseptically. 

Before  the  bladder  is  united,  if  it  is  to  be  done — and  many  sur- 
geons prefer  to  leave  all  the  wounds  freely  open — tlic  colpeurynter  is 
removed  from  the  rectum  and  the  catheter  from  the  urethra. 

My  own  personal  preference — after  having  used  no  drainage,  ure- 
thral drainage  by  catheter  tied  in,  drainage  through  a  tube  passed 
through  the  trigone  and  out  at  the  anus,  and  considered  the  French 
method  (two  tubes  passed  through  the  wound) — my  own  preference  is 
to  drain  through  a  perineal  puncture  and  tube  tied  in.  I  have  oper- 
ated only  in  three  cases  in  this  way,  all  severe  cases,  one  a  large  tumor, 
one  diffuse  villous  growth,  one  a  stone  over  two  and  a  half  ounces 
in  weight,  and  all  recovered.* 

The  objection  to  a  perineal  opening  is  that  it  is  a  source  of  extra 
hasmorrhage.  I  have  devised  a  method  of  performing  drainage  in 
this  region  which  I  think  does  away  with  this  objection.  I  pass  a 
staff  with  a  broad,  flaring,  central  groove  into  the  bladder.  With  a 
finger  in  the  rectum  as  a  guide,  having  its  tiji  placed  upon  the  apex 
of  the  prostate,  a  straight  bistoury,  such  as  is  used  in  median  lithotomy, 
is  passed  close  along  the  superior  wall  of  the  rectum  until  it  enters  the 
urethra  and  the  groove  of  the  staff  near  the  apex  of  the  prostate.  Now 
a  long  silver  probe  with  an  eye-hole  at  one  end,  having  been  pre- 
viously prepared  by  having  a  fine  stout  string  threaded  through  its  eye, 
which  string  in  its  turn  passes  through  the  tip  of  a  red  rubber  cath- 
eter, about  size  27  French,  and  out  through  its  lumen — being  knotted 
inside  the  lumen  so  that  it  will  not  pull  through — such  a  probe,  a  lit- 
tle curved  at  its  tip,  is  passed  along  the  blade  of  the  knife  as  a  guide 
into  the  urethra  and  bladder.  A  finger  passed  through  the  abdominal 
wound  easily  hooks  up  the  probe,  and  by  the  aid  of  the  string  and  the 
knot  the  catheter  is  drawn  through  the  small  punctured  wound  which 
it  accurately  fits — arresting  all  haemorrhage  by  its  own  pressure. 

The  chief  danger  of  this  operation  is  not  its  performance,  which  is 
exceedingly  simple,  but  in  the  possibility  of  cellulitis  afterward.  In 
my  opinion,  thorough  drainage  and  a  small  amount  of  tearing  during 
the  operation  are  the  best  means  of  averting  this. 

The  after-treatment  is  the  common  surgical  dressing  of  the  ab- 
dominal wound,  and  irrigating  the  bladder  once  or  twice  daily  with  a 
mild  current  of  hot  borax-water.  The  perineal  tube  should  be  taken 
out  at  the  end  of  four  days  to  a  week  ;  the  lower  drainage-tube  is  left 
in  the  abdominal  wound  twenty-four  hours.  If  urine  escapes  through 
it,  the  perineal  tube  is  returned ;  if  not,  the  abdominal  tube  is  taken 
out  twenty-four  hours  later.  I  have  had  my  patients  uniformly  up 
and  about  during  the  fourth  week — but  an  earlier  cure  is  possible. 

*  Loc.  cit. 


316  DISEASES  OF  THE   URETERS. 

The  higli  operation  is  entirely  suited  for  application  iji  the  female 
sex  in  cases  of  Yery  large  or  encysted  stone  and  foreign  bodies,  or  the 
complication  of  tumor. 


CHAPTER  XIX. 
DISEASES  OF  THE  URETERS. 

Anatomy.— Anomalies.— Chronic  Inflammation.— Dilatation.-Stricturc— Wounds. 

The  ureters  are  the  excreting  ducts  of  tlio  kidneys.  They  run 
down  on  either  side  behind  tlic  pcritonanim  from  the  kidney  over  the 
brim  of  the  pelvis  to  the  base  of  the  bladder,  and  pass  through  its 
coats  in  an  oblique,  valvular  way,  making  two  of  the  angles  of  the 
triffonum  Licutaudii,  of  which  the  internal  orifice  of  the  urethra  is 
the  third.  The  structure  of  the  ureters  is  mainly  muscular.  There 
is  an  inside  mucous  membrane,  then  come  the  circular  and  longitudi- 
nal layers  of  uustriped  muscle,  bound  together  by  connective  tissue. 

Xot  very  infrequently  the  ureter  is  double  or  triple;  the  abnor- 
mality existing  through  the  whole  length  of  the  canal,  or,  more 
commonly,  the  several  branches  uniting  above  at  a  distance  of  one  or 
more  inches  from  the  pelvis  of  the  kidney,  to  form  one  canal  from 
that  point  on  into  the  bladder.  Occasionally  there  is  but  one  ureter. 
Sometimes  the  ureter  ends  in  a  blind  extremity,  in  which  case  the 
kidney  can  not  functionate,  and  atrophies. 

W.  U.  Baker*  mentions  a  case  where  a  ureter  opened  abnormally 
near  the  urinary  meatus  in  a  woman.  A  cure  of  the  resulting  incon- 
tinence by  turning  the  ureter  into  the  bladder  by  a  cutting  operation. 
Baker  refers  to  a  similar  case  observed  by  Jackson,  and  quotes  Emmet 
for  a  case  of  ureter  entering  the  vagina  near  the  cervix.  When  the 
genitals  are  absent  in  the  male  the  ureters  often  open  into  the  rectum. 

The  diseases  of  the  ureter  are  few  and  unimportant,  being  for  the 
most  part  a  continuation  of  other  disease.  Wounds  of  the  ureter  alone 
are  very  uncommon.  Morris  cites  the  case  of  the  Archbishop  of  Paris, 
and  a  doubtful  one  by  Ilennen,  as  the  only  ones  on  record.  Chronic 
inflammation  of  the  ureter  extending  upward  from  the  bladder,  or 
downward  from  the  kidney,  exists,  but  is  hardly  worthy  of  considera- 
tion. Pressure  (by  tumor  or  otherwise)  upon  any  portion  of  the 
ureter  causes  the  canal  above  to  become  enormou.^ly  distended,  so  that 
it  may  reach  the  size  of  the  thumb  or  even  larger.  This  occurs 
markedly  in  exstrophy  of  the  bladder,  and  is  sure  to  happen  if  a 
kidney-stone  becomes  lodged  in  the  canal  on  its  way  to  the  bladder. 
*  "New  York  Medical  Journal,"  December,  1ST8,  p.  575. 


WOUNDS.  317 

Stricture  may  follow  the  injury  done  by  a  calculus  in  its  passage,  or 
malignant  or  tubercular  disease  may  extend  to  the  ureter  from  the 
bladder  or  kidney.  A  valvular  arrangement  of  the  lining  membrane 
of  the  ureter  has  been  noted.*  The  blood  in  haematuria  may  come 
from  the  ureters.  The  ureter  may  be  ruj^tured  by  external  violence, 
or  severed  by  a  wound — injuries  leading  often  to  fatal  extravasation 
of  urine,  or  to  ureteral  fistula  if  recovery  takes  place.  A  case  of  scir- 
rhous tumor  of  the  right  ureter,  observed  by  OUivier,  is  mentioned  by 
Sebeaux,f  leading  to  (reflex)  retention  of  urine,  and  directly  to  pyelitis 
and  death.  Nepveu  reports  |  two  cases  of  traumatic  anuria,  one  of 
"which,  was  due  to  the  transverse  section  by  a  gouge  of  the  left  ureter 
without  involving  the  bladder. 

Flaps  and  valve-like  folds  are  sometimes  found  within  the  ureter, 
notably  at  the  upper  end.  They  sometimes  lead  to  hydronephrosis. 
The  ureter  may  be  bent  upon  itself  at  an  angle  in  cases  of  displaced 
kidney.  Any  obstacle  to  the  free  outflow  of  urine  through  the  ureter 
tends  to  occasion  hydronephrosis.  Stricture  of  the  ureter  has  been 
noted.  F.  S.  Watson,  of  Boston,*  reports  a  case  of  double  hydro- 
nephrosis, due  to  organic  stricture  of  the  ureter  on  both  sides.  No 
cause  could  be  assigned.  There  was  no  reason  to  suppose  that  calcu- 
lus had  been  the  cause.  In  one  ureter,  two  centimeters  above  the 
bladder,  there  was  a  stricture  admitting  only  a  fine  knitting-needle. 
The  ureter  above  this  point  was  dilated  to  the  size  of  the  small  intes- 
tine. Watson  refers  to  four  other  cases  of  stricture  of  the  ureter  in 
literature — those  of  Kroner,  Galliard,  AyroUes,  and  one  from  "St. 
George's  Hospital  Eeports." 


CHAPTER  XX. 

DISEASES  OF  THE  KIDNEY. 

Anatomy. — Anomalies. — Floating  Kidney. — Nephrorraphy.— Injuries.  —  Suppression  of  Urine. — 
Nephralgia.— Pliosphatic  Urine.— Osaluria.— Gravel  and  Kidney-Stone.  —  Nephritic  Colic— 
Nephro-lithotomy. — Pyelitis,  Pyelonephritis,  and  Perinephritic  Abscess. — Pyelitis,  Pathological 
Lesions. — Causes. — Calculous  Pyelitis. — Perinephritic  Abscess. — Treatment  of  Pyelitis. — Hydro- 
nephrosis.— Kidney  Cysts.— Hydatids.— Tubercle.— Cancer.— Other  Timiors  of  the  Kidney.— 
Nephrotomy.— Nephrectomy.— Syphilis  of  the  Kidney. 

The  scope  of  this  work  does  not  warrant  a  description  of  all 
organic  and  functional  kidney-diseases.  Only  such  surgical  diseases 
are  here  dealt  with  as  are  most  frequently  encountered  by  the  practi- 

*  "Lancet,"  April  10,  1886,  p  688. 

t  "Contractures  du  Col  de  la  Vessie,"  Paris,  1876,  p.  44. 
X  "Gaz.  Hebd.  de  Med.  et  de  Chir.,"  February  16,  1877. 

*  "Boston  Medical  and  Surgical  Journal,"  November  26,  1885,  p.  505. 


318  DISEASES  OF  THE   KIDNEY. 

tioner  interested  in  genito-urinarv  surgery,  such  morbid  states  as  are 
liable  to  be  attended  with,  or  comi)licated  by,  functional  or  organic 
bladder-disease,  or  such  as  may  require  instrumental  interference  for 
their  relief. 

Anatomy. — The  kidney  lies  on  either  side  in  the  lumbar  region, 
liigh  up,  its  upper  border  reaching  above  the  last  two  false  ribs.  It 
has  the  familiar  shape  of  the  kidney-bean,  is  surmounted  above  by  the 
suprarenal  capsule,  like  a  cocked  hat,  and  lies  outside  of  the  peri- 
tonamm,  surrounded  by  fat,  with  its  hilum  directed  inward.  The 
healthy  adult  kidney  weighs  from  four  to  six  ounces.  It  is  sur- 
rounded by  its  own  investing  fibrous  capsule,  close  inside  of  which 
lies  the  secreting  or  cortical  portion  of  the  kidney,  dotted  by  its  in- 
numerable Malpighian  bodies,  and  containing  the  convoluted  urinif- 
erous  tubes ;  these  terminating  in  the  converging  straight  tubes  which 
unite  to  form  the  pyramids,  the  medullary  portion  of  the  kidney. 
The  pyramids  terminate  in  nipple-like  protuberances  called  papilla, 
which  dip  into  the  cavity  known  as  the  pelvis  of  the  kidney,  each 
jxipilla  surrounded  by  a  cup-like  cavity  in  the  pelvis  known  as  a  calix. 
All  of  these  calices  unite  to  form  the  cavity  of  the  pelvis  of  the  kidney 
from  which  the  ureter  is  given  off.  The  two  kidneys  are  sometimes 
united  at  their  upper  extremity,  forming  what  is  called  the  horseshoe- 
kidney,  usually  lying  astraddle  the  spine.  Sometimes  there  is  but  one 
kidney,  in  which  case  it  is  much  larger  than  usual.  Occasionally 
there  are  three  or  more.  Greenfield*  has  called  attention  to  the  fact 
that  where  there  is  congenital  absence  of  the  kidney  the  ureter  is 
absent,  and  the  seminal  vesicle  of  that  side  deficient.  Beumer  f  has 
collected  forty-eight  cases  where  the  kidney,  and  nearly  always  the  cor- 
responding ureter,  was  absent,  and  Eayer  J  mentions  a  girl — case  of 
M.  Moulon,  of  Trieste — who  died  at  fourteen,  having  no  kidneys,  no 
ureters,  and  no  bladder.  A  fluid  resembling  urine  had  during  her  life 
flowed  freely  from  her  umbilicus.  Instead  of  being  fixed  behind  the 
peritoneum  in  the  lumbar  region,  the  kidney  may  be  only  loosely  con- 
nected there,  and  may  become  displaced  in  the  abdomen,  and  freely 
movable  (floating  kidney).  Still  more  rarely  the  kidney  is  found  in 
an  abnormal  position  in  the  cavity  of  the  bony  pelvis,  or  elsewhere. 
If  one  kidney  is  absent,  atrophied,  or  diseased,  the  other  remaining 
healthy,  the  latter  undergoes  gradual  conservative  hypertrophy,  greatly 
increasing  in  size.  The  floating  kidney**  is  often  the  seat  of  pain, 
which  may  be  intense  at  times,  and  paroxysmal  in  its  occurrence. 
The  tight  dressing  of  women,  the  pregnant  condition,  and  heavy 
strains,  as  in  lifting,  may  cause  the  kidney  to  become  displaced  dovvn- 

*  "  Lancet,"  October  21,  1876. 

f  Virchow's  "Archiv,"  Ixx,  Heft  iv.  J  "Diseases  of  the  Kidney,"  1841. 

*  An  aflmirable  treatise  on  this  subject  is  "Die  Wanderniere  der  Frauen,"  Landau, 
Berlin,  1881.     Consult  also  F.  P.  Guiard,  "Du  Rein  mobile,"  P«ris,  1883. 


CONTUSIONS  AND   WOUNDS.  319 

ward  and  forwaid.  The  weight  alone  of  a,  diseased  kidney  may  cause 
its  displacement.  A  painful  floating  kidney  may  be  kept  more  or 
less  in  place  by  a  bandage  or  a  truss  with  a  large  pad.  When  a  kid- 
ney is  healthy,  but  the  seat  of  pain,  on  account  of  being  out  of  place, 
from  congestion  or  a  twist  in  the  ureter,  the  proper  treatment  is 
nephrorraphy. 

NEPHRORKAPnY. — ^This  operation  was  done  first  by  Ilahn,  of  Ber- 
lin. An  incision  is  made  about  an  inch  below  the  last  rib,  parallel 
to  it,  and  about  four  inches  long.  After  reaching  the  soft  yellow  fat 
about  the  kidney,  two  pairs  of  forceps  and  the  finger  may  be  used  to 
tear  through  the  fatty  capsule.  The  renal  capsule  being  reached,  it  is 
attached  to  the  edges  of  the  wound  by  several  sutures  of  strong  cat- 
gut. The  wound  is  to  be  dressed  open,  powdered  with  iodoform,  and 
stuffed  with  gauze  or  lint — or  otherwise  antiseptically  dressed. 

CONTUSIONS    AND  WOUNDS. 

The  kidney  is  sometimes  wounded  by  an  accident  not  necessarily 
fatal.  When  the  patient  survives  such  an  accident,  more  or  less  in- 
filtration of  the  tissues  by  urine  is  liable  to  follow.  The  kidney  itself 
inflames,  causing  partial  or  entire  suppression,  with  blood  in  the  urine, 
hot  skin,  high  pulse,  thirst,  headache,  pain  running  down  to  the  tes- 
ticle, vomiting,  etc.  Perhaps  abscess  results.  Contusions  are  more 
common.  The  kidney  may  be  ruptured  or  lacerated  by  a  fall,  by 
crushing  violence,  or  by  a  severe  blow.  Such  rupture  may  be  caused 
where  the  signs  of  external  violence  are  insignificant.  If  the  anterior 
surface  of  the  kidney  be  ruptured,  the  urine  may  escape  into  the  peri- 
tonseum,  giving  rise  to  fatal  peritonitis ;  if  the  posterior,  the  subserous 
tissues  will  be  infiltrated,  and  chills,  with  high  fever,  will  precede  the 
formation  of  pus.  The  contusion  may  injure  the  vitality  of  a  portion 
of  the  kidney,  but  not  be  attended  by  actual  laceration.  In  such  a 
case  there  would  be  more  or  less  acute  traumatic  nephritis,  terminating 
possibly  in  abscess. 

Seventy-one  cases  of  injury  to  the  kidney  without  external  wound 
are  collated  by  H.  Maas,  of  Freiburg,*  going  to  show  that  recovery 
from  such  injury  is  not  uncommon.  In  all  the  cases  but  six  there 
was  hgematuria  without  clots.  Injury  to  one  kidney  only,  when  un- 
complicated, proved  fatal  in  only  about  20  per  cent.  A  case  of  re 
covery  after  pistol-shot  wound  of  the  left  kidney  is  reported  by  A.  E. 
Cummins,  f 

The  symptojns  of  laceration  of  the  kidney  vary  in  degree  according 
to  the  extent  of  damage  done.  Collapse  usually  comes  on  at  once 
with  strong  tendency  to  vomit,  as  in  injuries  of  the  testicle.     There 

*  "  Deutsche  Ztsehrft  f .  Chir.,"  Bd.  x,  Hefte  1  und  2 
f  "Boston  Medical  and  Surgical  Journal,"  June  15,  1876. 


320  DISEASES   OF  THE   KIDNEY. 

is  pain  ovov  tlio  iiijurod  organ,  pain  running  down  the  ureter  into  the 
testicle  and  in  the  testicle  itself,  retraction  of  the  testicle;  often  pain 
across  the  liypogastrium,  and  a  heav}',  numb  feeling  in  the  thigh. 
The  urine,  which  may  require  to  be  drawn  at  first  through  the  cathe- 
ter, will  be'  usually  bloody,  scanty,  and  dense,  possibly  containing 
blood-casts  of  the  uriniferous  tubules,  and  frequently  long,  thin  clots 
— casts  of  the  ureter.     Signs  of  peritonitis  are  not  uncommon. 

2'he  pj'ognosis,  if  the  laceration  be  extensive,  is  almost  necessarily 
fatal;  if  it  be  slight,  the  patient  may  survive. 

Treatment  consists  in  absolute  rest,  ojiium  to  quiet  jiain,  and  the 
use  of  the  catheter  and  enema ta  to  secure  evacuation  of  the  dis- 
charges. No  cathartics  should  be  given,  fluids  should  be  used  epar- 
ingly,  diuretics  avoided,  cold  ap])lications  should  be  made  over  the 
injured  organ,  and  fluid  extract  of  ergot  administered.  Frequent  and 
careful  examinations  must  be  made  over  the  site  of  the  injured  kidney, 
and  an  exploratory  incision  as  soon  as  the  existence  of  pus  is  suspected. 
An  early  and  free  incision  is  of  great  importance,  as  pus  tends  to  bur- 
row downward  and  forward,  giving  rise  to  great  constitutional  irrita- 
tion. If  no  pus  be  discovered,  the  infiltrated  urine  may  be  evacuated, 
and,  in  any  case,  an  early,  free,  and  deep  incision  can  do  no  harm. 

Ilenry  Morris,*  whose  section  upon  this  subject  is  one  of  the  best 
in  medical  literature,  suggests  the  performance  of  lumbar  nephrectomy 
if  the  patient  has  "profuse  and  continuous  hcematuria,  especially  if 
the  bleeding  is  rapid  and  arterial." 

SUPPRESSION    OF    URINE. 

In  suppression  no  fluid  comes  down  the  ureters  into  the  bladder. 
Suppression  may  be  caused  by  fright  or  strong  mental  emotions,  by  in- 
jury to  the  kidneys,  or  the  onset  of  an  inflammatory  attack,  by  the 
effect  of  cold  or  other  cause  ;  sometimes,  especially  if  the  kidney  be  the 
seat  of  previous  chronic  disease,  by  operations  on  the  bladder  or  ure- 
thra, or  even  by  the  introduction  of  a  sound  or  lithotrite  {aee  Uretheal 
Fever),  by  the  passage  of  kidney-stone,  etc. 

The  symptoms  are  depression,  languor,  with  apprehension,  more  or 
less  fever,  with  hot,  dry  skin,  and  hard  pulse.  There  may  or  may  not 
be  chill,  vomiting,  headache,  and  pain  in  back  and  loins,  with  constipa- 
tion. No  urine  is  voided,  or  only  a  little  high-colored  secretion.  In- 
stead of  these  active  symptoms,  suppression  may  come  on  gradually 
from  advancing  chronic  kidney  disease,  the  amount  of  urine  passed 
from  day  to  day  gradually  diminishing.  In  the  latter  case  there  is 
usually  anasarca,  in  the  former  not.  Meanwhile  the  urea  and  prod- 
ucts of  tissue-metamorphosis  are  accumulating  in  the  blood,  and  the 
patient  becomes  poisoned  by  them.     Drowsiness  and  stupidity,  per- 

*  "Surgical  Diseases  of  the  Kidney,"  1886. 


NEPHRALGIA.  32] 

haps  delirium  and  coma,  come  on  ;  there  may  be  convulsions,  and  the 
patient  dies  in  from  two  to  five  days,  unless  the  flow  of  urine  can  be 
re-established  Before  death  the  skin  and  breath  have  a  urinous,  ca- 
daveric smell ;  there  may  be  localized  paralysis. 

In  spite  of  this  customary  course  of  events,  instances  of  total  sup- 
pression for  very  many  days  have  been  recorded  with  a  favorable  issue. 
I  remember  to  have  seen  reports  of  two  such  cases  after  scarlet  fever, 
one  of  seventeen,  the  other  of  thirty  days,  but  I  can  not  vouch  for 
them.  H.  Morris  alludes  to  the  very  problematical  case  of  Vieusseux 
of  Geneva,  suppression  for  seventeen  months,  with  recovery. 

Diagnosis  is  easy.  In  retention  the  bladder  is  full,  and  can  be  felt 
above  the  pubes,  the  difficulty  usually  being  to  introduce  a  catheter. 
In  suppression,  the  catheter  glides  in  readily,  but  the  bladder  is  found 
nearly  or  quite  empty. 

Treatment. — Dry  cups  and  hot  fomentations  over  the  kidneys. 
Hot-air  bath  and  hydragogue  laxatives,  to  favor  excretion  of  urea  by 
the  intestinal  mucous  membrane ;  the  free  use  of  warm  drints,  flax- 
seed-tea,  etc.  ;  and,  if  there  be  no  inflammatory  condition,  full  doses 
of  the  acetate  or  citrate  of  potash  and  of  infusion  of  digitalis,  consti- 
tute the  treatment.  Turpentine  should  be  avoided.  Hyoscyamus 
may  be  given,  and  morphine  subcutaneously. 

In  old  cases  of  chronic  bladder  and  kidney  disease,  suppression  is 
an  exceedingly  dangerous  symptom,  and  does  not  yield  readily  to 
treatment.  It  signifies  extension  of  .inflammation  to  the  excretive 
structure  of  the  kidneys,  and  is  the  normal  termination  of  this  class  of 
diseases. 

NEPHRALGIA. 

Pain  over  the  region  of  the  kidney  is  a  symptom  by  no  means  con- 
fined to  diseases  of  that  organ.  It  is  found  with  many  morbid  bladder 
and  prostatic  conditions,  and  very  often  is  simple  lumbago,  not  depend- 
ent upon  any  internal  malady.  In  bladder  and  prostatic  diseases  the 
pain  in  the  back  is  more  likely  to  occupy  the  sacral  region,  particularly 
the  sacro-iliac  synchondrosis  on  one  or  both  sides.  In  lumbago  the 
pain  is  usually  much  worse  in  damp  weather,  or  on  the  approach  of  a 
storm  ;  is  aggravated  usually  by  motion  of  the  trunk,  particularly  in 
rising  from  a  sitting  posture.  There  is  a  popular  impression  that  all 
kidney-diseases  are  attended  by  pain  in  the  back,  the  severity  of  the 
disease  regulating  the  amount  of  pain.  This  impression  is  incorrect. 
Some  kidney-diseases  are  attended  by  pains  in  the  back,  others  are  not. 
There  is,  however,  a  variety  of  pain  in  the  back  which  has  its  seat  in 
the  kidney,  and  which  is  known  as  nephralgia.  This  pain  is  deep 
seated,  felt  in  the  back  over  the  kidney,  usually  unilateral,  often  ex- 
tending down  around  the  side,  following  the  course  of  the  ureter, 
sometimes  continuing  on  into  the  testicle,  sometimes  complicated  by 

21 


322  DISEASES  OF  THE  KIDNEY. 

bladder-symptoms  suggestive  of  stone  in  tlio  bladder,  or  of  ehrouic  cys- 
titis of  the  neck.  The  pain  varies  in  intensity,  and  is  usually  made 
worse  by  fatigue.  Pressure  generally  aggravates,  sometimes  relieves 
it.  Often  the  patient  can  not  lie  in  bed  upon  the  affected  side.  The 
l)aiu  is  usually  a  dull,  deep  ache,  occasionally  sh:ir]i,  darting,  pricking  in 
character.  It  may  come  on  gradually  or  suthlonly,  and  remains,  ac- 
cording to  its  cause,  from  a  short  time  up  to  many  years,  perhaps  un- 
til death.  Nephralgia  is  in  reality  a  symptom,  but  may  come  on  in  a 
severe  form  independently  of  any  organic  disease. 

Cau.sei^. — The  main  causes  of  nephralgia  are  very  acid  urine,  kid- 
ney-stone, organic  kidney-disease  (pyelitis,  cancer,  any  morbid  deposit 
or  tumor),  and  many  other  morbid  conditions,  special  diseases, 
abdominal  aneurism,  etc.  It  may  owe  its  origin  to,  and  be  kejjt  up 
by,  perversion  of  the  sexual  function,  or  ungratilied  sexual  desire. 
Over-acid  urine  is  in  itself  a  sufficient  and  a  not  infrequent  cause. 
The  urine  in  health  is  slightly  acid,  especially  'after  fasting.  As  a 
rule,  however,  in  the  healthy  state  there  is  an  alkaline  tide  (as  Eoberts 
has  denominated  it)  to  the  urine,  which  comes  on  after  each  meal,  and 
lasts  several  hours.  The  heavier  the  meal  the  later  but  the  more  last- 
ing the  tide.  In  the  morning,  with  American  habits  of  living,  it 
occurs  at  about  10.30  o'clock. 

The  urine,  then,  shortly  after  breakfast,  should  be  normally  neu- 
tral, or  even  faintly  alkaline,  and,  if  then  quite  acid,  a  diagnosis  of 
over-acid  urine  may  be  safely  made.*  The  causes  of  over-acidity  of 
tlie  urine  are  the  rheumatic  diathesis,  old  age,  the  use  of  wines  and 
liquors,  but  especially  of  fermented  malt  liquors,  ale,  beer,  etc.,  and 
of  sweet,  sparkling  wines  (champagne).  The  latter  of  the  above- 
mentioned  causes  act  directly  as  irritants  to  the  urinary  tracts  by  pro- 
ducing large  quantities  of  sharp-pointed  crystals  of  uric  acid  which 
mechanically  scrape  and  irritate  all  portions  of  the  mucous  membrane. 
The  urine  may  be  over-acid  while  its  true  character  is  masked  by  some 
bladder  or  kidney  inflammation  which  furnishes  enough  (volatile) 
alkali  to  neutralize  the  whole  flow.  This  source  of  error  has  to  be 
constantly  guarded  against.  There  are  no  inflammatory  conditions, 
acute  or  chronic,  of  any  portion  of  the  urinary  passages  which  are  not 
distinctly  aggravated  by  over-acid  urine,  while  some  of  them  are 
caused  in  the  first  instance  by  it.  Hence  it  becomes  a  part  of  the 
hygiene  of  the  urinary  passages  to  see  that  the  alkaline  tide  exists, 
say  at  eleven  o'clock  in  the  morning,  and,  if  it  does  not,  to  cause  it 

*  If  the  patient  has  ne;ilcctcd  to  pass  water  before  breakfast,  the  very  acid  urine  col- 
lected (lurinp;  the  night  may  not  be  neutralized  by  the  alkaline  tide.  Simple  mention  of 
this  fact  will  preclude  error;  nor  is  it  necessary  to  test  only  the  urine  voided  during  the 
few  hours  after  breakfast,  for  this  is  alkaline  often  where  habitual  over-acidity  exists 
none  the  less.  The  practical  test  is  this :  urine  should  be  voided  on  rising  in  the  morn- 
ing, and  not  again  till  10.30,  at  which  hour  it  should  be  neutral,  or  very  faintly  acid. 


NEPHRALGIA— TREATMENT.  323 

to  do  so  by  attention  to  hygienic  laws  and  the  internal  administration 
of  a  suitable  medicine.  In  all  cases  of  nephralgia  where  careful  ex- 
amination fails  to  detect  any  tumor  of  the  kidney,  or  any  disease  of 
the  bladder  or  prostate,  suspicion  should  fall  at  once  upon  an  over-acid 
state  of  the  urine  as  being  the  cause,  or  possibly  retained  kidney-stone 
with  pyelitis,  or  pyelitis  from  some  other  cause. 

Diagnosis. — To  decide  between  these  affections,  a  careful  examina- 
tion of  the  urine  is  necessary  after  excluding  bladder  and  prostatic 
disease.  In  pyelitis  there  will  be  constantly  more  or  less  pus  in  the 
urine.  In  nephralgia  due  to  over-acid  urine  the  alkaline  tide  is  usu- 
ally absent  ;  crystals  of  oxalate  of  lime  and  of  uric  acid  may  be  found 
in  tlie  urine  when  passed,  while  the  color  is  usually  deep,  and  the  spe- 
cific gravity  constantly  high.  There  may  be  also  in  the  urine  more  or 
less  pus  proportionate  to  the  amount  of  irritation  produced  by  the 
acid  urine  and  the  duration  of  the  complaint.  Such  urine  when  left 
to  stand  in  a  glass  may  become  almost  solid  on  cooling,  by  the  precip- 
itation of  pink  amorphous  urates,  or,  if  the  latter  ingredient  be  not  suffi- 
ciently abundant  to  produce  this  result,  a  blue  line,  like  the  bloom  on 
a  plum,  will  form  around  the  top  of  the  glass  just  at  the  edge  of  the 
urine.  Finally,  after  a  few  hours  such  urine  may  begin  spontaneously 
to  deposit  large  red.  crystals  of  uric  acid  upon  the  sides  and  bottom  of 
the  glass. 

Prognosis. — The  deep-seated,  dull,  boring  pain  over  one  or  both 
kidneys  may  last  for  years,  kept  up  by  over-acid  urine,  in  patients 
of  sedentary  habits  whose  nervous  tone  is  depressed  by  overwork,  alco- 
hol, or  tobacco.  Nephralgia  very  often  coexists  with  irregular  use  of 
the  sexual  organs,  or  ungratified  desire. 

The  treatment  is  slowly  but  surely  effective  unless  there  exists  or- 
ganic mischief.  It  consists  in  a  properly  regulated  hygiene,  much 
out-door  exercise,  Turkish,  Russian,  or  other  baths,  dry  frictions  of 
the  skin  daily  with  hair  gloves,  rather  light  diet,  the  avoidance  of 
overwork  and  of  the  abuse  of  alcoholic  beverages  (particularly  fer- 
mented liquors)  and  of  tobacco.  In  persistent  cases  of  pure  nephral- 
gia in  young  adult  males  the  hygiene  of  the  sexual  organs  is  almost 
invariably  at  fault,  and  requires  attention.  An  acquaintance  with 
this  fact  is  the  key  to  successful  treatment  in  many  cases.  The  means 
detailed  above,  aided  by  half-drachm  doses  of  citrate  of  potash  three 
times  daily,  or  the  plentiful  use  of  Vichy  or  other  alkaline  water,  will 
usually  sooner  or  later  get  the  better  of  the  complaint.  If  a  laxative 
is  needed,  about  3  vij  of  Friedrichshalle  water,  to  which  a  little  hot 
water  is  added,  may  be  taken  with  benefit  one  hour  before  breakfast 
every  morning.  In  some  instances  when  the  digestion  is  at  fault  a 
mineral  acid  in  a  bitter  vegetable  infusion  does  more  good  than  the 
exhibition  of  alkalies. 


324  DISEASES  OF  THE  KIDNEY. 

PHOSPHATIC    URINE. 

In  connection  with  the  above,  the  converse  state,  over-alkaline 
urine,  shonkl  be  referred  to.  Here  the  nrine  is  habitnally  neutral  or 
alkaline,  while  the  alkaline  tide  is  unduly  marked.  Tiie  lluid  is  pale, 
of  light  speciHc  gravity,  and  often,  after  standing  a  few  hours  in  a 
glass  vessel  at  ordinary  temperatures,  it  commences  to  decompose. 
Such  urine,  when  i)assed,  often  has  a  faint  mutton-broth  or  chicken- 
soup  odor,  and  the  last  drachm  or  more  of  the  How  is  very  apt  to  be 
as  white  as  milk,  from  an  excess  of  precipitated  amorphous  phosphates. 
This  white  flow  is  not  constant.  It  may  come  only  with  the  alkaline 
tide  after  breakfast.  It  is  a  cause  of  unceasing  anxiety  to  many  pa- 
tients, who  believe  it  to  be  seminal  fluid.  Tiie  urine  when  set  aside 
shows  the  glossy,  iridescent,  phosphatic  pellicle  very  quickly,  instead 
of  the  faint  bluish  line  at  the  top  of  the  fluid  on  the  glass,  which  is 
produced  by  urine  rich  in  urates.  Phosphatic  urine  is  apt  to  contain 
crystals  of  oxalate  of  lime  wiien  passed,  and  to  show  at  once  or  shortly 
afterward  innumerable  bacteria,  the  rapid  development  of  which  is 
undoubtedly  due  to  the  presence  of  phosphate  of  lime.  Phosphatic 
urine  alternates  from  time  to  time  with  over-acid  urine,  so  that  the 
same  patient  may  have  for  a  few  days  a  dirty-brown  sediment  of  urates 
in  his  chamber,  which  he  sometimes  mistakes  for  blood,  and  then  for 
a  few  succeeding  days  a  dense  white  deposit  which,  if  his  sexual  rela- 
tions be  not  perfectly  natural,  he  is  pretty  sure  to  consider  seminal 
fluid.  The  alternations  sometimes  seem  to  depend  upon  the  greater 
or  less  amount  of  mental  worry  an 4  physical  exercise,  the  quantity 
and  quality  of  the  food,  and  the  condition  of  the  digestion.  Some- 
times both  deposits  exist  in  excess  at  the  same  time,  so  that  the  dis- 
charge may  be  creamy  as  it  comes  from  the  bladder,  and  deposit  an 
enormous  amount  of  urates  and  phosi^hates,  recalling  the  solid  urine 
of  snakes  and  birds. 

The  symptoms  found  with  phosphatic  urine  are  usually  those  of 
lassitude,  listlessness,  a  feeling  of  general  weakness  often  attended  by 
despondency.  There  are  usually,  also,  dull,  continuous  pain  in  the 
back  of  the  head,  and  unsatisfactory  digestion. 

Phosphatic  urine  depends  usually  upon  nervous  exhaustion,  and  is 
often  associated  with  weak  digestion,  a  diet  formed  mainly  of  the  sac- 
charine and  starchy  food,  with  a  dislike  for  meat.  Excessive  use  of 
tobacco  aggravates  any  existing  tendency  to  the  production  of  phos- 
phatic urine  ;  masturbation,  or  excessive  venery,  often  leads  to  it  by 
exhausting  the  nervous  force  ;  mental  anxiety  and  worry  produce  it 
temporarily.  Thus,  students  who  study  all  night,  before  some  critical 
examination,  are  certain  to  have  an  excess  of  phosphates  in  their  urine 
on  the  following  day.  In  the  same  way,  any  continued  mental  ten- 
sion, anxiety,  or  fatigue,  may  produce  it.     As  may  be  inferred  from 


OXALURIA.  325 

its  etiology,  this  affection  is  mostly  confined  to  youth  and  early  adult 
age. 

The  treatment  consists  in  removing  the  cause,  if  possible,  re-estab- 
lishing mental  quietude,  cutting  off  tobacco,  tea,  and  coffee,  encour- 
aging pleasant  out-door  relaxation,  with  travel,  change  of  scene,  and 
air. 

As  medicine,  phosphoric  acid,  dilute  hydrochloric  acid,  with  or 
without  a  little  strychnine,  iron,  or  quinine,  and  perhaps  some  bitter 
vegetable  infusion  or  tincture,  are  usually  employed,  and  would  seem 
to  be  indicated  as  appropriate  tonics.  The  cause  of  phosphatic  urine 
is  evidently  associated  with  morbid  action  of  the  ganglionic  nervous 
centers,  affecting  the  secondary  assimilation  of  food,  and  those  reme- 
dies which  are  most  effectual  in  correcting  this  curious  and  unpleasant 
condition  are  measures  which  place  the  patient  under  the  influence  of 
more  favorable  conditions  of  life  temporarily.  Hence,  a  trip  to  the 
mountains,  camping  out,  sea-voyage,  etc.,  are  more  potent  in  securing 
relief  than  any  drug. 

OXALURIA. 

The  octahedral  crystals  of  oxalate  of  lime,  together  with  (less  fre- 
quently) the  dumb-bell  crystals,  the  little  spherules  and  the  amorphous 
dust  of  the  same,  are  not  infrequently  found  in  the  urine,  either  alone 
or  coexisting  with  crystals  of  uric  acid,  and  with  deposits  of  amorphous 
phosphates  or  urates.  Such  urine  is  often  acid,  dense,  and  high- 
colored.  Sometimes  the  crystals  appear  accidentally  in  the  urine  from 
the  free  use  of  rhubarb,  or  indeed  of  tomatoes.  Usually,  but  not 
necessarily,  the  crystals  appear  in  cases  of  disturbed  or  exhausted  nerve- 
power  and  imperfect  digestion.  They  are  found  also  with  some  dis- 
eases of  the  brain  and  spinal  cord.  Nervous  prostration,  produced  by 
excessive  venery,  is  quite  likely  to  be  associated  with  them.  In  short, 
nervous,  irritable,  hypochondriacal  individuals,  especially  of  the  gouty 
temperament,  particularly  if  young,  with  perverted,  overstimulated, 
or  ungratified  sexual  desires  ;  if  overfed,  under-exercised,  and  leading 
a  sedentary  life — such  patients  frequently  have  oxalate  of  lime  in  their 
urine,  and  suffer  from  an  interminable  series  of  unusual  complaints, 
with  which  they  are  pretty  sure  to  torment  their  physician  as  well  as 
themselves.  The  oxalate  of  lime  is  not  a  cause  of  the  disorder,  but 
rather  a  symptom.  These  cases  are  met  by  hygiene,  change,  and  a 
proper  regulation  of  all  that  has  gone  astray.  If  enough  of  any  alkali 
be  given  to  render  the  urine  abundant  and  limpid,  the  oxalate  of  lime 
will  occasionally  disappear  for  a  time  ;  and  this  course  is  advisable,  as 
well  as  the  frequent  use  of  baths,  to  free  the  blood  as  much  as  possible 
from  any  effete  materials  which  may  have  been  collecting  there.  The 
true  curative  treatment,  however,  is  purely  hygienic,  and  based  upon 
a  correct  appreciation  of  the  causes.    As  a  rule,  the  less  medicine  taken 


326  DISEASES  OF  THE  KIDNEY. 

the  better.     The  mineral  acids  and  strychnine  seem  sometimes  to  do 
good  as  tonics  ;  an  out-door  life  sometimes  cures. 

QRAVEL    AND    KIDNEY- STONE. 

The  solid  substances  naturally  held  in  solution,  and  excreted  with 
the  urine,  are  sometimes  precipitated  in  the  crystalline  form  in  the 
kidney-tubules,  or  at  other  jjortions  of  the  urinary  passages,  and  voided 
as  crystals,  always  visible  with  the  microscope,  sometimes  to  the  unaided 
eye.  This  is  gravel.  The  cause  of  its  precipitation  lies  in  the  fact 
that  the  urine  becomes  too  concentrated — too  heavy  in  organic  con- 
stituents. As  most  frequently  met  with  in  practice,  gravel  is  com- 
posed of  uric  acid,  and  forms  the  red  sand  which  quickly  collects  around 
the  sides  and  bottom  of  the  vessel  containing  the  urine.  The  gouty 
constitution  predisposes  to  the  formation  of  this  red  sand,  especially 
when  aided  by  a  sedentary  life  and  high  living,  more  nutriment  being 
ingested  than  can  be  disposed  of,  especially  meats  and  alcoholic  bever- 
ages, among  which  new  fermented  liquors  and  sweet,  effervescing  wines 
hold  the  first  rank.  Gravel  is  more  frequently  seen  in  summer  than 
at  other  seasons,  on  account  of  the  greater  activity  of  the  skin,  which 
leaves  less  fluid  to  be  excreted  by  the  kidneys,  and  consequently  leads 
directly  to  a  concentration  of  the  urine.  The  tendency  to  the  forma- 
tion of  gravel  is  often  hereditary. 

The  symptoms  occasioned  by  gravel  are  those  set  down  for  nephral- 
gia, and,  added  to  them,  often  symptoms  of  a  low  grade  of  cystitis  or 
urethritis — the  smarting,  burning  sensations  on  urination  being  espe- 
cially prominent.  All  bladder  or  urethral  inflammations  are  greatly 
aggravated  by  the  existence  of  "red  sand"  (sharp  crystals  or  concre- 
tions of  uric  acid)  in  the  urine. 

Treatment. — xVfter  what  has  been  so  frequently  repeated  in  previous 
sections,  of  the  ill  effects  of  highly-acid  urine,  it  is  needless  to  delay 
long  with  the  consideration  of  gravel.  An  abundance  of  alkaline  dilu- 
ents for  a  few  days  will  always  cause  the  red  sand  to  disappear,  and 
the  sym^jtoms  occasioned  by  it  will  shortly  afterw^ard  cease  to  be  trouble- 
some in  pure  cases  of  gravel.  The  true  treatment  is  preventive  ;  that 
is,  so  regulating  the  food,  drink,  exercise,  and  h3'giene  of  living,  that 
the  offensive  ingredient  may  cease  to  ajipear.  To  effect  this,  the  con- 
stant use  of  some  mild,  pleasant,  alkaline  fluid  (such  as  Vichy  water) 
is  often  desirable.  It  is  well  to  take  a  draught  of  this,  or  some  other 
fluid,  before  retiring,  and  between  meals,  for  the  purpose  of  diluting 
the  urine  of  fasting.* 

From  gravel  to  kidney-stone  is  but  a  single  step.  It  is  only  neces- 
sary for  some  of  the  crystals  to  be  detained  for  a  time  in  the  kidney 
and  there  form  a  nucleus,  and  we  have  at  once  kidney-stone.     Such 

*  For  treatment,  consult  section  on  the  preventive  treatment  of  urinary  calculus. 


GRAVEL   AND   KIDNEY- STONE— TREATMENT.  327 

detentions  of  crystalline  material  in  the  kidney  do  occur.  Attentive 
examination  of  sections  of  kidneys  after  death  will  sometimes  reveal 
numerous  yellowish  or  brown  striae  running  from  the  papilla?  toward 
the  base  of  the  pyramids.  These  depend  upon  the  precipitation  of 
amorphous  urates  in  the  straight  kidney-tubules,  and  are  usually  caused 
by  the  pont-mortem  cooling  of  the  body,  which  diminishes  the  solu- 
bility of  this  ingredient  and  occasions  its  deposit.  In  still-born  infants, 
and  in  children  dying  within  forty-eight  hours  after  birth,  these  striae 
are  not  infrequently  found  composed  of  uric  acid.  A  similar  precipi- 
tation of  urates,  uric  acid,  or  oxalate  of  lime,  may  occur  during  life. 
If  it  be  washed  out  by  the  urine  accumulating  above,  we  have  some 
sand  or  amorphous  dust  in  the  voided  fluid.  But  such  concretions 
may  become  impacted  and  permanently  lodged  in  the  urinary  tubules. 
Here  they  may  cease  to  grow,  or  may  increase  in  size  in  the  kidney- 
substance,  leading,  perhaps,  to  the  formation  of  cysts,  by  occlusion. 
Finally,  these  concretions,  when  washed  down  by  the  urine,  may  fail 
to  escape  from  the  pelvis  of  the  kidney  and  become  lodged  in  one  of 
the  calices  or  in  the  pelvis  itself.  A  nucleus  once  existing  in  this 
situation  becomes  a  foreign  body,  and  goes  on  increasing  in  size  by 
the  deposition  of  new  crystals  or  amorphous  matter  furnished  by  the 
urine. 

The  precipitation  may  occur  primarily  in  the  infundibula  or  pelvis 
of  the  kidney.  The  number,  size,  and  shape  of  these  kidney-concre- 
tions vary  infinitely.  Several  hundreds  of  them  have  been  found  in  a 
single  kidney  after  death.  They  vary  in  size  from  a  pin-head  to  a 
nut,  and  may  reach  the  weight  of  several  ounces  in  old  cases.  They 
are  usually  smooth,  oval  in  shape,  or  with  facets  from  mutual  friction, 
if  several  of  them  lie  together ;  or  they  may  assume  every  variety  of 
prolongation  and  arborization.  They  may  be  rough  on  the  surface, 
especially  if  composed  of  oxalate  of  lime,  or,  if  they  excite  pyelitis, 
their  surfaces  may  become  incrusted  with  triple  and  amorphous  phos- 
phates. Blood-clot,  portions  of  hydatid  cysts,  or  little  masses  of  con- 
crete pus,  may  serve  as  the  nucleus  for  renal  calculus,  or  act  as  the 
colloid  in  which  the  crystals  form. 

Tlie  symptoms  of  kidney-stones  are  variable.  As  long  as  they  are 
small  and  do  not  excite  inflammation,  or  become  engaged  in  the  orifice 
of  the  ureter,  the  patient  may  not  be  informed  of  their  joresence  by  a 
single  unnatural  sensation,  so  that  an  auto^Dsy  may  first  reveal  an  un- 
suspected kidney-stone.  Occasionally  they  attain  large  size,  and  even 
destroy  extensive  portions  of  the  kidney  by  pressure,  without  occasion- 
ing any  symptom  to  attract  the  patient's  attention.  Again,  symptoms 
of  kidney-stone,  with  joaroxysms  of  pain,  may  exist  for  a  time,  and 
then  cease,  either  because  the  stone  has  occluded  the  ureter  and  led 
to  atrophy  of  the  kidney,  or  because  it  has  become  encysted  and  has 
ceased  to  irritate  the  mucous  membrane,  or  to  oppose  the  escape  of 


328  DISEASES  OF  TUE  KIDNEY. 

urine.  Sooner  or  later,  however,  kidney-stones  usually  manifest  their 
presence  in  one  of  three  ways,  either  by  setting  up  inflammation  of  the 
pelvis  of  the  kidney  (calculous  pyelitis),  by  their  passage  into  the  blad- 
der (nephritic  colic),  or  by  remittent  or  persistent  nephralgia. 

The  aching  i)ain  in  the  small  of  the  back,  with  all  its  aecoin]ianying 
symptoms,  as  detailed  under  the  head  of  nei)hralgia,  may  depend  on 
kidney-stone.  This  pain  is  usually  made  worse  by  pressure,  but  there 
is  no  distinctive  character  to  it  which  enables  the  surgeon  to  decide 
positively  whether  the  pain  depends  upon  retained  stone  or  other  cause. 
When,  however,  the  cause  lies  in  kidney-stone,  while  the  crystals  in  the 
urine  remain  the  same,  it  may  sometimes  be  noticed  that  the  blood- 
disks,  oval,  round,  and  spindle-shaped  epithelial  cells  and  scattered 
pus-cells,  Avhich  the  urine  is  pretty  sure  to  contain,  become  increased 
in  quantity  after  exercise,  while  they  sensibly  diminish,  or  perhaps 
entirely  disappear,  after  rest  in  bed  for  a  few  days.  The  microscope 
in  these  cases  ahvays  shows  the  characteristic  rounded  epithelial  cell 
from  the  kidney  pelvis — a  cell  one  half  or  one  third  larger  in  diameter 
than  the  ordinary  pus-cell. 

Treatment. — This  may  be  summed  up  in  what  has  been  said  in 
connection  with  the  subject  of  urinary  calculus,  under  the  head  of 
solvent  treatment ;  and  what  is  to  be  said  after  the  section  on  nephritic 
colic  concerning  uephro-lithotomy. 

NEPHRITIC    COLIC. 

When  a  kidney-stone  engages  in  the  orifice  of  a  ureter  and  attempts 
to  pass  into  the  bladder,  it  gives  rise,  usually,  to  well-marked  symptoms. 
Kidney-pains  may  sometimes  be  occasioned  by  the  dislodgment  of  a 
calculus  from  an  infundibulum  into  the  pelvis  of  the  kidriey,  or  from 
one  portion  of  the  pelvis  into  another.  They  become  most  severe, 
however,  when  the  ureter  is  entered.  The  pain  is  marked  by  its 
paroxysmal  character.  It  commences  suddenly,  perhaps  seizing  the 
patient  while  at  a  meal,  or  at  any  time  when  seemingly  in  the  best  of 
health,  perhaps  most  frequently  shortly  after  rising  in  the  morning. 
It  shoots  down  the  ureter  into  the  scrotum  and  to  the  end  of  the  penis. 
The  testicle  of  the  affected  side  is  often  strongly  retracted.  Some- 
times in  a  severe  paroxysm  the  whole  scrotum  and  penis  are  drawn  up 
into  a  hard  knot,  as  it  were,  giving  the  patient  the  idea  of  squeezing, 
dragging,  twisting,  of  these  organs.  The  pain  may  also  extend  down 
the  thigh  on  the  affected  side.  There  is  usually  an  incessant  desire  to 
pass  water,  with  sometimes  almost  entire  suppression.  What  little 
urine  is  voided  comes  away  high-colored,  and  in  small  quantities  at  a 
time,  often  tinged  with  blood  and  mixed  with  epithelium  from  the  kid- 
ney. Pain  attends  urination,  chiefly  toward  its  close,  running  down  to 
the  end  of  the  penis.     During  the  paroxysms,  especially  if  severe,  faint- 


NEPHRITIC   COLIC.  329 

ness,  nausea,  and  vomiting  come  on  ;  tlic  skin  is  covered  with  a  cold 
sweat ;  the  patient  tosses  restlessly  about,  seeking  relief,  but  finding 
none.*  In  the  intervals  of  the  paroxysms  there  is  a  sense  of  soreness 
and  discomfort,  perhaps  amounting  to  continued  pain,  or  the  relief 
may  be  more  positive  if  the  concretion  be  small.  Usually,  after  a 
number  of  paroxysms,  lasting  from  a  few  hours  to  many  days,  suddenly 
all  pain  ceases  at  once.  The  calculus  has  droj)ped  into  the  bladder, 
and  the  suffering  is  over.  Instead  of  this  happy  termination,  the 
stone,  after  having  engaged  in  the  upper  end  of  the  ureter,  may  drop 
back  into  the  pelvis  of  the  kidney.  Relief  of  the  severe  pain  follows, 
but  the  patient's  condition  is  an  unenviable  one,  for  perhaps  the  stone 
is  too  large  to  pass.  Again,  the  paroxysms  of  j)ain  may  extend  over  a 
long  series  of  days  or  weeks,  coming  on,  perhaps,  at  a  certain  hour  every 
day,  or  at  longer  intervals.  In  one  (personal)  case,  the  paroxysms 
came  every  Sunday,  in  the  afternoon,  for  several  weeks.  This  perio- 
dicity may  be  so  marked  as  to  give  rise  to  the  idea  of  some  malarial  ele- 
ment in  the  case.  It  is  needless  to  add  that  quinine  does  not  control 
the  paroxysms.  In  this  way  the  symptoms  may  linger  along  indefi- 
nitely, tiring  out  both  patient  and  surgeon. 

A  termination  always  to  be  feared  is,  impaction  of  the  calculus  in 
the  ureter.  In  such  cases,  the  patient  will  indicate  some  spot  along 
the  course  of  the  ureter  where  he  feels  constant  pain,  increased  by  local 
pressure.  The  pain  will  be  less  severe  than  during  the  paroxysms,  but 
it  will  be  constant.  A  stone  is  most  apt  to  halt  near  the  outlet  of  the 
ureter  into  the  bladder.  If  the  ureter  is  blocked  up  almost  entirely, 
the  function  of  the  kidney  on  that  side  will  be  interfered  with.  The 
ureter  above  the  obstruction,  and  the  pelvis  of  the  kidney,  will  fill  up 
with  urine,  subjecting  the  secreting  structure  of  the  kidney  to  pressure, 
and  perhaps  occasioning  drowsiness,  headache,  with  symptoms  of  mild 
ursemia.  If  the  other  kidney  be  diseased,  or  its  ureter  obstructed, 
these  symptoms  wall  be  by  so  much  the  more  certain  to  ensue.  If  the 
other  kidney  and  ureter  be  sound,  enough  urine  may  trickle  past  the 
stone  to  prevent  these  symptoms  from  being  marked.  In  such  cases 
the  ureter  above  the  stone  gradually  dilates,  as  does  also  the  pelvis  of 
the  kidney,  pressing  upon  and  causing  the  gradual  atrophy  of  the 
kidney-substance,  so  that  after  death  the  ureter  may  be  found  as  large 
as  the  small  intestine,  containing  perhaps  several  stones,  while  the 
kidney  is  replaced  by  a  fibrous  sac,  more  or  less  distended  with  puru- 
lent fluid,  inflamed  or  ulcerated  ;  or  perhaps  by  a  mass  of  semi-solid 
pus  (pyo-nephrosis),  or  hydro-nephrosis  may  come  on.  The  effect  upon 
the  ureter  at  the  point  of  impaction  of  the  stone  is  to  cause  ulceration, 
with  perhaps  the  growth  of  granulations,  which  bleed  easily  and  may 
give  rise  to  haematuria.     Sometimes,  after  being  lodged  for  a  while,  a 

*  If  the  paroxysms  be  severe  and  long  continued,  more  or  less  fever,  -with  great  thirst, 
hot  skin,  and  quick  pulse,  results. 


330  DISEASES  OF  TUE  KIDNEY. 

stone  will  finally  pass,  but  the  ulceration  of  the  ureter  left  behind  by 
it  may  go  ou  to  the  formation  of  stricture  and  the  production  of  the 
same  results  as  if  the  stone  had  remained. 

After  a  stone  has  finally  entered  the  bladder,  the  symptoms  cease. 
The  constaiU  desire  to  urinate  is  rarely  a;:rg"ravated  by  the  presence  of 
the  small  foreign  body,  although  sometimes  irritability  is  increased. 
Anything  which  will  pass  the  ureter  will  also  pass  the  urethra,  if  the 
latter  be  not  strictured.  Such,  indeed,  is  usually  the  case,  and,  after 
the  cessation  of  the  pains  in  an  attack  of  kidney-colic,  the  urine 
should  be  carefully  watched  ;  for  the  little  calculus,  which  caused  so 
much  distress  in  getting  into  the  bladder,  may  reach  the  outer  world 
without  giving  any  evidence  of  its  passage.  It  is  always  a  satisfac- 
tion to  find  the  stone,  both  to  confirm  the  diagnosis  and  to  insure 
against  the  fear  of  subsequent  stone  in  the  bladder.  Sometimes  the 
stone  is  large  enough  to  cause  considerable  pain  in  passing  the  urethra, 
or  indeed  it  may  become  lodged  there.  Lastly  and  not  uncommonly, 
the  stone  once  in  the  bladder  and  the  patient  relieved,  he  recovers 
from  his  irritability  and  forgets  his  pains,  thinking  himself  well.  In 
this  dangerous  state  of  unconcern  he  lives  perhaps  for  years,  the  stone 
constantly  growing  by  new  accretions,  but  not  occasioning  much  dis- 
tress, until  finally,  from  some  new  exciting  cause  (cold,  exercise),  or 
in  the  natural  course  of  events,  he  suddenly  breaks  down  with  a  sharp 
attack  of  acute  cystitis,  and  upon  search  a  stone  of  some  size  is  found 
in  the  bladder. 

Diagnosis. — Kidney-colic  is  not  liable  to  be  mistaken.  In  severe 
nephralgia  from  highly  acid  urine  or  gravel,  there  may  be  similar 
paroxysms  of  pain,  but  the  testicle  is  not  so  apt  to  be  retracted,  nor  the 
paroxysm  to  be  so  severe.  The  passage  of  blood-clots  or  of  hydatids 
through  the  ureter,  as  well  as  kidney-stone,  occasions  true  colic.  An 
inspection  of  what  is  passed  by  the  urethra  can  alone  clear  up  such 
cases,  which  are  exceedingly  rare.  The  patient's  previous  history  or 
antecedents  often  furnish  valuable  presumjttive  evidence.  An  indi- 
vidual having  once  passed  a  stone  is  always  liable  to  have  another  one 
form,  unless  he  regulates  his  life  so  as  to  avoid  the  causes  of  acid  con- 
centrated urine.  Absolute  diagnosis  may  be  made  in  some  instances 
in  the  female  by  sounding  the  kidney  through  the  ureter  by  Simon's 
method,  but  the  manceuvre  is  difficult  of  execution,  and  is  rarely  at- 
tempted. The  greatest  difficulty  of  diagnosis  lies  in  distinguishing 
the  early  stages  of  tubercular  pyelitis  from  kidney-stone,  but  a  close 
study  of  the  history,  a  microscopic  study  of  the  cells  from  the  kidney- 
pelvis,  will  often  lead  a  close  observer  to  the  correct  conclusion. 
Perhaps  the  one  most  constant  symptom  of  kidney-stone  is  the  pas- 
sage of  blood  more  or  less  freely  from  the  kidue}'',  mingled  with  cells 
from  the  kidney-pelvis  coming  from  the  first  and  second  epithelial 
layer — this  sign  coming  on  notably  after  jolting  exercise. 


NEPHROLITHOTOMY.  33 1 

Treatment. — During  tlio  i)aroxy.sms,  prolonged  immersion  of  the 
whole  body  in  very  hot  water,  or  the  local  use  of  dry  cups  and  hot 
fomentations,  may  produce  relaxation.  If  the  pain  become  unbear- 
able, ether  by  inhalation  should  be  given,  sufficient  to  moderate  it. 
Kneading  the  course  of  the  ureter  is  occasionally  of  service.  A  sud- 
den change  of  position  may  sometimes  dislodge  a  stone  after  it  has  be- 
come engaged  in  the  orifice  of  a  ureter ;  but,  once  engaged,  it  is  bet- 
ter that  it  should  pass.  Opium  or  belladonna  may  be  used  by  the 
rectum  when  the  pains  are  protracted  and  the  attack  promises  to  be 
a  long  one.  It  is  of  the  first  importance  to  promote  a  free  secretion 
of  urine,  so  as  to  act  upon  the  stone  from  behind  by  an  abundance 
of  liquid  pressure.  This  is  effected  by  warm  drinks,  half-drachm 
doses  of  acetate  or  citrate  of  potash  every  few  hours,  or  half-ounce 
doses  of  infusion  of  digitalis,  until  free  diuresis  is  produced.  The 
use  of  diuretic  mineral  waters  is  not  of  much  service  during  an  at- 
tack of  kidney-colic,  but  the  free  use  of  light  beer  is  sometimes  very 
efficacious.  These  means  should  be  persisted  in  intelligently,  if  the 
stone  become  impacted  in  the  ureter.  If  the  stone  fail  to  reach  the 
bladder,  being  retained  in  the  kidney  or  impacted  in  the  ureter,  or 
in  any  case  of  kidney-stone  where  the  diagnosis  is  quite  clear,  the 
proper  treatment  is  nephrolithotomy. 

After  one  attack  of  nephritic  colic,  the  patient  must  be  instructed 
in  the  proper  course  of  life  to  follow  in  order  to  avoid  the  formation 
of  another  stone.  The  diet  should  be  low  and  largely  vegetable,  and 
the  use  of  all  alcoholic  stimulants  interdicted,  especially  the  use  of  new 
fermented  liquors.  Plentiful  out-door  exercise  should  be  taken,  and 
the  reaction  of  the  urine  be  watched.  Vichy  water  or  some  mild  alka- 
line diuretic  should  be  adopted  as  an  habitual  beverage  to  keep  the 
urine  abundant  and  diluted.  The  patient  should  also  acquire  a  habit 
(Roberts)  of  taking  a  full  draught  of  water  between  meals,  and  on  re- 
tiring, so  as  to  dilute  the  urine  of  fasting,  which  is  normally  concen- 
trated and  over-acid.  The  alkaline  tide  after  taking  food  insures 
against  the  formation  of  stone  during  those  periods. 

NEPHROLITHOTOMY. 

This  operation  owes  much  of  its  present  repute  to  the  successful 
efforts  of  Henry  Morris,  who  states  that  at  the  date  of  his  treatise 
upon  the  "  Surgical  Diseases  of  the  Kidney  "  *  it  had  been  performed 
twenty-one  times  with  two  deaths  :  one  from  an  overdose  of  morphia, 
one  from  suppression  of  urine  and  disease  in  the  other  kidney. 
These  cases  are  exclusive  of  those  in  which  the  kidney  was  the  seat  of 
abscess  or  formed  a  tumor  in  the  side. 

The  operation  was  first  performed  by  Morris  in  1880.     He  advises 

*  Op.  cit.,  pages  471  and  525. 


332  DISEASES  OF  THE  KIDNEY. 

an  incision  four  and  a  half  inches  lonir.  parallel  with  the  last  rib  and 
f  hreo  quarters  of  an  inch  below  it.  The  outer  edge  of  the  quadratus 
Inmborum  may  be  incised  if  the  muscle  is  in  the  way  at  the  bottom  of 
the  wound.  After  all  haemorrliage  is  arrested,  the  operator  tears 
through  the  perirenal  fat  witli  two  pairs  of  forceps.  Tiiis  fat  be- 
comes soft  as  the  kidney  is  approached,  unless  there  has  been  peri- 
renal inflammation,  in  which  case  it  may  be  dense  and  tough. 

AVhen  the  kidney  is  reached,  its  w'hole  posterior  surface  and  the 
pelvis  are  explored  with  the  ])ulp  of  the  finger,  feeling  for  any  inequal- 
ity of  surface  or  extra  hardness  or  resistance  at  any  spot.  The  ab- 
dominal wall  must  be  supported  during  this  manipulation,  to  keep 
the  kidney  from  being  pushed  forward  by  the  exploring  finger. 

If  nothing  is  found  indicating  the  presence  of  stone,  the  kidney- 
substance  should  be  punctured  in  numerous  places,  and  the  several 
calices  of  the  kidney  similarly  explored — all  this  in  a  systematic  man- 
ner. If  this  manoeuvre  fails  to  detect  stone,  the  fingers  are  passed 
around  the  outer  edge  of  the  kidney,  and  the  front  surface  explored 
by  palpation,  and  the  kidney  may  be  squeezed  between  the  thumb 
and  finger.  In  spite  of  all  this  a  stone  may  escape  detection.  Morris 
says  that  he  removed  by  nephrectomy  a  kidney  having  imbedded  in  it 
a  calculus  as  large  as  a  marble,  which  he  was  unable  to  localize  either 
before  the  kidney  was  removed  or  after  it  was  out  by  pressing  it 
upon  the  table  or  between  the  thumb  and  finger.  Morris  advises  that, 
if  no  stone  be  found,  the  kidney  should  not  be  removed  until  each  of 
the  calices  has  been  opened  and  explored. 

"When  the  stone  is  located,  the  overlying  kidney-substance  should 
be  incised  with  a  straight  bistoury  and  the  stone  removed  with  finger 
or  forceps.  The  kidney-substance  should  be  incised  in  preference  to 
the  pelvis  of  the  organ,  if  the  stone  can  be  conveniently  reached 
through  such  an  incision,  because  the  wound  heals  more  promj)tly. 
If  the  stone  be  large  or  branched,  it  is  better  to  break  it  and  remove 
the  pieces  separately. 

After-treatment. — A  drainage-tube  should  be  left  in  and  the 
whole  wound  closed  by  sutures.  Urine  will  cease  to  flow  through  the 
wound  in  a  period  varying  from  a  few  days  to  a  few  weeks.  Anti- 
septic dressings  are  applied,  the  drainage-tube  running  through  them 
into  some  boracic  cotton  or  other  absorbent  dressing.  Under  the 
whole  a  large  pad  of  German  moss  peat  may  be  placed  to  absorb  the 
urine.     The  dressings  must  be  changed  often. 

Complications  like  hgemorrhage,  cellulitis,  abscess,  are  met  by  ap- 
propriate surgical  means.  Fistula  may  follow,  but  is  not  common. 
Morris  mentions  one  case  of  hernia  (easily  reducible)  following  the 
operation. 


PYELITIS— CAUSES.  333 

PYELITIS,    PYONEPHROSIS,    AND    PERINEPHRITIC    ABSCESS. 

Pyelitis  is  an  inflammation  of  the  pelvis  and  calices  of  the  kid- 
ney. Like  most  other  inflammations  of  the  urinary  passages,  it  is 
usually  encountered  in  practice  in  the  chronic  form,  undergoing  per- 
haps from  time  to  time  acute  exacerbations.  The  pathological  ap- 
pearances in  the  acute  form  are,  a  uniform  redness  of  the  mucous 
membrane,  frequently  dotted  in  a  punctate  manner  with  little  eccliy- 
motic  spots,  or  perhaps  with  free  blood  on  the  surface  of  the  mem- 
brane. There  may  be  false  membranes  attached  to  the  surface  of  the 
pelvis  or  blocking  up  a  ureter,  otherwise  the  fluid  contained  in  the 
kidney  is  a  mixture  of  urine,  pus,  blood,  with  more  or  less  epithelium. 
In  chronic  pyelitis  the  membrane  is  thickened,  tough,  pale,  bluish- 
gray,  crossed  by  branching  vessels.  There  may  be  spots  of  ulceration. 
Eayer  describes  vesicles  of  the  size  of  a  pin's  head  studding  the  mu- 
cous membrane  in  many  chronic  cases.  Rarely  the  ulcers  are  covered 
by  deposits  of  triple  phosphates.  Sometimes  the  surface  of  the  mem- 
brane is  distinctly  granular.  There  are  found,  perhaps,  within  the 
pelvis  of  the  kidney,  cancerous  or  cheesy  tubercular  deposits,  hydatids 
or  other  entozoa,  kidney-stones  incrusted  or  not  with  phosi3hates,  etc. 

Where  there  has  been  obstruction  of  the  ureter,  the  condition 
known  as  pyonephrosis  is  liable  to  be  encountered  after  death,  namely 
atrophy,  more  or  less  complete,  of  the  secreting  or  tubular  portions  of 
the  kidney  with  dilatation  of  the  pelvis  and  calices,  the  kidney  being, 
perhaps,  replaced  by  a  large  pouched  sac  filled  with  semi-solid  pus  or 
pus  and  blood,  with  precipitated  phosphates  and  urates.  The  septa 
between  the  pouches  may  be  calcified  or  imperfectly  ossified.  Some- 
times the  pus  is  absolutely  solid,  and  seems  to  be  stratified,  so  that  it 
can  be  removed  in  layers  ;  often  it  is  cheesy,  with  soft  spots.  Some- 
times the  pus  collected  in  the  kidney  pelvis  has  ulcerated  its  way  out, 
giving  rise  to  perinephritic  abscess.  It  may  point  externally,  leaving 
behind  a  fistulous  tract  which  usually  remains  permanent.  Occasion- 
ally after  pyelitis  the  kidney  atrophies  instead  of  becoming  pyone- 
phrotic.  Pyelitis  is  more  often  double  than  single.  If  it  depend  upon 
a  cause  acting  on  one  side  only  (impacted  stone),  the  other  kidney 
may  be  healthy,  although  enlarged  by  conservative  hypertrophy. 

Pyelitis  is  usually  kept  up  by  some  cause,  and  the  problem  for 
treatment  is  not  so  much  to  remove  the  inflammation  from  the  pelvis 
of  the  kidney  as  it  is  to  remove  the  cause  which  occasions  it. 

Causes. — Pyelitis  is  not  an  idiopathic  disease.  Of  all  the  numerous 
causes  which  may  produce  it,  three  are  in  constant  action  in  the  com- 
munity, and  furnish  the  bulk  of  the  cases.     These  are — 

1.  Chronic  prolonged  obstruction  to  the  free  escape  of  urine  from 
the  bladder,  and  chronic  inflammation  of  the  latter  organ,  or  acute 
inflammation,  notably  gonorrhoeal. 


334  DISEASES  OF  THE  KIDNEY. 

'2.  The  retention  of  kidnoN'-stone,  or,  more  nircl}',  its  impaction  in 
a  ureter. 

3.  Tubercular  disease,  neoplasms,  and  other  local  irritants. 

(1)  The  first  of  these  causes  is  constantly  at  work  in  stricture  and 
prostatic  hyper troi)hy.  Here  the  bladder  becomes  inllamed,  the  dam- 
ming back  of  the  urine  is  felt  by  the  kidneys,  and  their  mucous  mem- 
branes are  kej)t  constantly  more  or  less  congested,  until  finall}',  from 
some  provocation,  such  as  cold  or  retention,  or  the  use  of  instruments 
in  the  bladder,  an  acuter  phase  of  inflammation  is  set  up  in  the  latter 
organ,  which  is  very  prone  to  travel  rapidly  up  the  ureters  and  locate 
itself  permanently  in  a  chronic  form  upon  the  pelves  of  the  kidneys. 
Here  it  remains  in  a  subacute  state,  suffering  occasional  exacerbations 
of  acuteuess,  and  liable  to  become  complicated  by  inflammation  of  the 
secreting  structure  of  the  kidue}',  attended  by  uraemic  symj^toms  and 
speedy  death.  Pyelitis  under  these  circumstances  is  mild  in  charac- 
ter, does  not  occasion  any  severe  symptoms,  and  goes,  for  the  most 
part,  unnoticed  by  i)aticnt  and  surgeon.  Its  presence  may  always  be 
inferred  in  old  cases  of  obstructive  j)rostatic  and  urethral  disease,  and 
it  must  be  remembered  that  in  these  diseases  danger  to  life  is  more  to 
be  apprehended  from  this  than  from  any  other  quarter. 

In  several  cases  of  acute  p^'elitis  due  to  the  extension  of  gonor- 
rhceal  cystitis  upward,  I  have  noticed  a  remarkable  absence  of  fever, 
pain,  or  any  symptoms  directly  pointing  toward  the  kidney  ;  on  the 
contrary,  the  cases  have  been  almost  always  treated  as  if  the  bladder 
were  alone  involved.  I  can  not  say  that  this  condition  is  uniform, 
but  it  is  not  uncommon — a  mention  of  it  is  enough  to  put  the  surgeon 
on  his  guard. 

(2)  One  of  the  most  frequent  causes  of  such  pyelitis  as  manifests 
itself  during  life  by  positive  symptoms  referable  to  the  kidney,  is  stone 
retained  in  the  kidney.  By  the  same  mechanism  as  in  the  bladder 
will  stone  in  the  kidney  sooner  or  later  give  rise  to  inflammation  of 
the  mucous  membrane  upon  which  it  rests.  Stone  impacted  in  a  ure- 
ter inevitably  leads  to  the  same  result  by  distention  of  the  pelvis  of 
the  kidney  with  retained  urine,  and  by  the  secondary  decomposition 
of  the  fluid,  the  mechanism  being  similar  to  that  causing  cystitis  with 
atony,  from  prolonged  retention  of  urine.  Hence  anything  which 
will  cause  prolonged  distention  of  the  pelvis  of  the  kidney,  retention 
of  urine,  blood,  entozoa,  false  membrane,  etc.,  blocking  up  a  ureter, 
is  able  to  occasion  pyelitis.  Pressure  of  the  pregnant  uterus  in  the 
female  probably  acts  in  the  same  way,  in  inducing  that  fatal  form  of 
pyelitis  attending  lying-in  women,  even  where  there  is  no  pya?mia. 

(3)  Besides  the  above  causes,  a  host  of  others,  may  be  enumerated 
as  more  rare.  Thus,  the  irritating  action  upon  the  kidneys  of  turpen- 
tine, of  constantly  over-concentrated,  over-acid  urine  ;  the  existence 
of  chronic  forms  of  Bright's  disease ;  the  deposit  of  cancerous  or  tu- 


PYELITIS— SYMPTOMS.  335 

bercular  matter  in  the  walls  of  the  kidney-pelvis  ;  foreign  bodies  other 
than  stone  ;  worms,  hydatids,  clots,  etc.  Pyelitis  also  attends  certain 
diseases  as  a  complication  at  times,  the  eruptive  fevers,  typhus,  cliolera, 
etc.,  and  is  found  not  infrequently  with  pytemia  and  carbuncle. 

Symptom!^. — Pyelitis  is  usually  attended  by  pain  in  the  back,  of 
the  same  character  as  that  described  in  the  section  on  nepliralgia. 
This  pain  is  made  worse  by  pressure,  and  is  usually  confined  to  the 
affected  side,  although  there  may  be  pain  over  both  kidneys  when 
only  one  is  diseased.  When  the  affection  depends  on  kidney-stone, 
usually  there  have  been  some  attacks  of  nephritic  colic  more  or  less 
marked.  Occasionally,  however,  the  disease  comes  on  in  an  insidi- 
ous manner,  with  little  or  no  pain  in  the  back,  what  symptoms  there 
are  being  referred  to  the  bladder.  Sometimes  paroxysms  of  pain,  re- 
sembling nephritic  colic,  are  experienced  where  there  is  and  has  been 
no  stone.  Early  in  the  disease  the  urine  will  usually  be  found  to  con- 
tain blood-disks,  a  little  excess  of  mucus,  with  many  small,  round, 
oval,  spindle-shaped,  and  irregular  epithelial  cells,  such  as  abound  in 
the  pelvis  of  the  kidney.  There  is  a  trace  of  albumen  depending  on 
the  blood,  and  the  urine  reacts  acid.  As  the  disease  advances  the 
epithelial  scales  are  replaced  by  pus-cells,  not  in  clusters,  but  evenly 
distributed  through  the  urine,  giving  it  a  uniform,  turbid  appearance 
when  voided.  The  amount  of  pus  steadily  increases  in  quantity,  the 
urine  usually  remaining  strongly  acid  ;  on  standing,  this  pus  settles 
down  into  a  dense,  greenish,  oily-looking  deposit.  Violent  exercise 
increases  the  nephralgia  and  the  amount  of  pus  in  the  urine.  Often 
the  pus  diminishes  greatly  in  quantity  for  some  days,  and  suddenly 
reappears  in  excess.  This  phenomenon  is  especially  noticeable  when 
the  kidney  has  become  sacculated.  The  pus  retained  in  a  sacculus 
accumulates  there,  until  finally  it  bursts  its  barriers  and  reappears  in 
quantity  for  a  day  or  two,  when  it  will  again  cease  to  flow  abundantly, 
until  the  sacculus  has  had  time  to  refill.  The  pain  in  the  flank  is 
often  greater  when  the  pus  is  not  flowing,  and  any  swelling  existing 
there  is  apt  to  become  more  prominent.  These  variations  in  the 
amount  of  pus  are  less  marked  when  both  kidneys  are  affected.  In 
rare  cases  there  may  be  no  discharge  of  pus  whatever,  as  when  the 
ureter  is  absolutely  occluded. 

Chills  of  varying  duration  and  intensity  are  often  present,  espe- 
cially if  the  kidney  is  sacculated  and  contains  large  amounts  of  pus. 
These  rigors  may  assume  the  quotidian  or  tertian  type,  and  recur  with 
great  regularity,  especially  in  the  evening. 

One  symptom  of  pyelitis  is  very  liable  to  lead  to  error  of  diagnosis, 
especially  if  the  pain  in  the  back  has  not  been  prominent  and  no 
tumor  exists  in  the  flank.  This  symptom  is  frequent  micturition. 
This  irritability  is  due  to  reflex  action,  and  by  it  the  bladder  is  stimu- 
lated to  repeated  contractions,  and  many  a  case  of  pyelitis  has  been 


336  DISEASES  OF  THE  KIDNEY. 

treated  as  chronic  cystitis,  powerful  injections  being  thrown  into  the 
bhidder  in  the  vain  hope  of  controlling  the  formation  of  \n\s,  which 
is  supposed  to  have  its  origin  there.  The  bowels  usually  act  irregu- 
larly, diarrhani  and  constipation  alternating  with  eacli  other,  due  to 
inflammatory  adhesions  between  the  dilated  kidney  and  tlie  colon,  or 
to  the  more  mechanical  jiressure  of  a  distended  pyone])hrotic  kidney 
upon  the  large  intestine  passing  over  it.  "When  the  kidney  becomes 
dilated  and  sacculated  by  the  pressure  of  accumulated  pus,  a  tumor  is 
formed,  wliich  is  tender  on  pressure,  sometimes  affording  a  feel  of 
deep  fluctuation,  more  or  less  perceptible  to  sight  and  touch,  accord- 
ing to  its  size,  sometimes  becoming  ap]u-eciably  smaller  after  a  free 
discharge  of  pus  in  the  urine.  The  position  usually  occupied  by  such 
a  tumor  is  in  the  flank  between  the  last  ribs  and  crest  of  the  ilium.  On 
the  right  side  the  transverse  colon  may  separate  the  tumor  from  the 
liver,  but  this  diagnostic  sign  may  be  absent,  from  inflammatory  ad- 
hesions having  taken  place  between  the  coverings  of  the  two  glands. 
The  tumor  formed  by  a  pyonephrotic  kidney  is  occasionally  large 
enough  to  extend  across  the  middle  line  of  the  abdomen. 

As  the  disease  advances  the  patient  becomes  cachectic,  pale,  and  de- 
bilitated. Hectic  fever  may  set  in  and  close  the  scene,  the  patient 
being  worn  out  by  constant  suppuration,  or  poisoned  by  the  urea, 
which  can  not  lind  an  exit  through  his  altered  kidneys.  Ulceration 
of  the  pelris  of  the  kidney  may  occur,  especially  if  it  contain  stone, 
and,  through  an  opening  thus  made,  pus  and  urine  may  infiltrate  the 
tissues,  forming  pcrincphritic  abscess.  This  points  in  the  back  or 
under  Poupart's  ligament  (simulating  psoas  abscess),  or  opens  into  the 
bladder  or  pleural  cavity,  into  the  lung,  or,  more  commonly,  into  the 
intestine — rarely  into  the  peritoneal  cavity.  A  distended,  sacculated, 
jiyonephrotic  kidney  in  the  same  way  may  contract  inflammatory 
adhesions  to  all  the  surrounding  tissues,  and  finally  break  and  burrow 
in  any  of  the  above  directions.  The  tumor  subsides  rapidly  Avhen 
the  jient-up  matter  has  found  an  outlet,  but,  unless  the  calculus  or 
other  offending  body  escapes,  or  is  extracted  through  the  opening,  a 
permanent  fistula  is  pretty  sure  to  remain.  When  such  an  abscess 
breaks  into  the  bladder,  bowel,  or  lungs,  the  subsidence  of  the  tumor 
is  attended  by  a  copious  discharge  of  pus  at  the  anus,  urethra,  or 
mouth.  After  the  abscess  has  discharged  itself  and  remained  fistulous 
for  a  time,  in  some  favorable  cases,  it  may  gradually  shrivel  and  dry 
up,  owing  to  total  atrophy  of  the  kidney,  and  in  such  cases,  if  the 
other  kidney  be  healthy,  the  patient  recovers  completely. 

Perinepliritic  abscess  does  not  necessarily  depend  for  its  origin 
upon  antecedent  kidney-disease.  It  may  come  on  as  the  result  of 
fatigue  and  a  straining  exertion  of  the  muscles  about  the  kidney-re- 
gion, from  cold  or  other  cause.  Three  exceedingly  interesting  exam- 
ples of  perinephritic  abscess,  not  caused  by  or  attended  with  any 


PYELITIS— SYMPTOMS.  337 

kidney-disease,  are  reported  by  Dr.  H.  J.  Bowditch^  in  a  paper  read 
before  the  Boston  Society  for  Medical  Observations,  May  4,  1808.  Tn 
each  of  these  there  was  a  distinct  tumor  in  the  right  loin,  witii  the 
usual  train  of  symptoms,  chills,  hectic,  etc.  ;  in  each  there  was  pul- 
monary and  pleuritic  complication,  with  discharge  of  pus  by  the 
mouth,  the  matter  having  made  its  way  up  along  the  sheath  of  the 
psoas  muscle  into  the  pleural  cavity ;  and  in  each  there  was  marked 
relief  of  all  symptoms  and  ultimate  recovery  after  a  timely  opening 
into  the  tumor,  which  was  made  in  two  of  the  cases  before  fluctuation 
could  be  distinctly  felt.  In  two  of  the  cases  the  kidney  was  recog- 
nized by  the  exploring  finger  free  in  the  cavity  of  the  abscess,  but 
neither  microscopic  nor  chemical  test  applied  to  the  urine  revealed 
the  presence  of  kidney-disease.  These  cases  demonstrate  the  advan- 
tage of  early  opening  for  perinephritic  abscess. 

Generally  perinephritic  abscess  is  due  to  kidney-disease  primarily. 
This  may  be  calculous  pyelitis  with  obstruction,  or,  perhaps  more 
often,  the  suppuration  of  a  tubercular  kidney.  The  collection  of  pus 
may  be  enormous.  Heustis,*  of  Mobile,  drew  from  a  suppurating 
kidney  by  an  incision  in  the  back  three  pints  of  pus,  and  his  patient 
made  a  good  recovery.  I  have  operated  several  times,  the  relief  being 
instantaneous  and  more  or  less  complete.  G.  Nieden's  f  paper  is  a 
valuable  one,  tabulating  one  hundred  and  sixty-six  cases.  V.  P.  Gib- 
ney  J  has  contributed  to  our  knowledge  of  the  affection  as  occurring  in 
children. 

Instead  of  breaking  externally,  a  pyonephrotic  kidney,  after  its 
secreting  substance  has  become  atrophied,  may  consolidate  into  a  hard, 
cheesy  mass,  and  cease  to  give  trouble.  One  perfectly  good  kidney  is 
sufficient  for  life.     Unfortunately,  the  disease  is  most  often  double. 

Prognosis. — The  prognosis  of  pyelitis  depends  upon  its  cause. 
The  milder  cases,  occurring  with  stricture  or  prostatic  disease,  cease  to 
be  troublesome  after  successful  treatment  of  the  latter.  The  forms 
occurring  with  fevers,  pleurisy,  and  zymotic  diseases  often  get  well 
quickly  if  the  primary  disease  spares  the  patient.  In  pyeemia  and 
carbuncle  the  complication  aggravates  the  prognosis.  Depending 
upon  local  cancer  or  tubercle,  the  affection  does  not  get  well.  With 
hydatids  or  calculus  it  is  severe,  but  not  necessarily  fatal.  Double 
pyelitis  is  always  grave.  Where  there  is  pyonephrosis  the  chances  of 
recovery  are  not  great,  but  with  one  sound  kidney  there  is  always 
hope.  Autopsies  have  revealed  wasted,  withered  sacs,  perhaps  clasp- 
ing a  stone,  or  a  mass  of  hard,  concrete  pus,  whose  existence  had 
never  been  suspected  during  life.     Discharge  of  the  pus  by  other  than 

*  "Am.  Journ.  Med.  Sci.,"  Oct.,  18Y5,  p.  457. 
t  "Deutsch.  Archiv  f.  klin.  Med.,"  Nov.,  18'78,  p.  451. 

X  "Am.  Journ.  of  Obstetrics,"  vol.  ix.  No.  1,  April,  ISTG,  and   "Chicago  Medical 
Jo'.irnal  and  Examiner,"  June,  1880. 
22 


338  DISEASES  OF  THE  KIDNEY. 

the  natural  channel  is  often  speedily  fatal,  excej^t  in  favorable  cases 
where  the  opening  occurs  tlirough  the  loins. 

Treatment. — When  pyelitis  depends  upon  bladder,  prostatic,  or 
urethral  disease,  its  treatment  is  identical  with  that  of  its  cause.  The 
same  is  true  of  cancer,  tubercle,  etc.  In  fever,  zymotic,  or  scorbutic 
disease,  the  main  malady  must  be  treated,  care  being  exercised  to  pre- 
vent the  urine  from  becoming  too  acid  and  concentrated.  Where  it 
is  attended  with  considerable  hcemorrhage,  tannin,  gallic  acid,  acetate 
of  lead,  opium,  ergot,  or  other  styptics,  may  be  advantageously  tried, 
and  borncic  acid,  the  bcnzoates,  or  nai)htharine,  if  tlie  urine  is  offen- 
sive and  the  stomach  will  tolerate  the  drugs. 

During  an  acute  attack  of  pyelitis,  with  great  pain,  high  fever, 
frequent  urination  of  bloody  purulent  matter,  wet  cups  over  the  kid- 
ney, hot  baths,  hot  local  fomentations,  warm  diluent  drinks,  and 
opium  to  allay  pain  and  spasms,  are  the  main  features  of  treatment. 
In  chronic  cases,  however,  such  as  are  not  infrequently  met  with  in 
practice,  where  there  is  reason  to  suspect  kidney-stone,  and  where  con- 
stant suppuration  is  wearing  out  the  patient,  the  surgeon's  duty  lies 
in  puttiug  him  into  the  best  possible  hygienic  conditions,  giving  him 
the  advantage  of  rest,  country  air,  and  a  sustaining  diet,  with  sucli 
tonics  as  iron,  quinine,  and  cod-liver  oil.  Roberts  speaks  highly  of 
large  doses  of  muriated  tincture  of  iron.  Alkaline  diluents  will  some- 
times diminish  the  amount  of  pus,  by  making  the  urine  less  concen- 
trated. Wine  is  often  serviceable,  and  in  some  cases  the  mineral 
acids  improve  the  digestion,  increase  the  strength,  and  better  the 
condition  of  the  urine.  Tlie  vegetable  astringents,  alum,  and  the 
terebinthinates,  are  occasionally  useful  as  stimulants  to  the  mucous 
membrane  in  chronic  cases. 

If  there  is  reason  to  suspect  kidney-stone,  palliation  must  be  de- 
pended upon  unless  the  patient  will  submit  to  nephrolithotomy,  an 
operation  growing  in  favor  and  especially  suitable  for  this  class  of 
cases.  The  solvent  treatment  can  not  be  relied  upon.  At  best  it 
may  do  some  good  in  cases  of  acid  kidney-stone  where  there  is  no 
pyelitis.  But,  when  the  pelvis  of  the  kidney  is  in  a  catarrhal  sta<"e 
from  sui^puration,  the  stone  becomes  covered  externally  with  a  layer 
of  phosphates  which  at  once  protects  it  from  any  possible  solvent 
action  of  an  alkaline  diuretic. 

When  there  is  pyonephrosis,  with  sacculation  of  the  kidney  and  a 
tumor  which  can  be  felt  in  the  flank,  two  courses  of  treatment  are 
open  : 

1.  The  general  treatment  by  tonics,  astringents,  and  hygiene, 
keeping  up  the  patient's  strength  in  every  way,  and  encouraging  him 
to  wait  for  final  atrophy  of  the  kidney  and  desiccation  of  the  pus, 
using  all  the  means  suggested  above  for  chronic  pyelitis  with  contin- 
ued suppuration. 


HYDRONEPHROSIS.  339 

2.  The  operation  of  opening,  or  even  removing  the  kidney. 

The  former  course  is  hardly  justifiable  at  the  present  day.  Unless 
the  general  condition  of  the  patient  is  such  as  wholly  to  forbid  any 
operation,  an  incision  in  the  loin  is  the  proper  treatment  for  pus  re- 
tained in  the  kidney  or  lying  about  it.  The  risk  of  the  operation  is 
moderate,  far  less  than  that  of  leaving  the  pus  to  burrow  its  own  way 
toward  the  surface.  Nephrotomy  is  the  treatment  after  the  aspirat- 
ing needle  finds  pus.  There  is  no  fear  of  wounding  the  peritoneum 
if  the  back  or  flank  be  perforated,  as  the  kidney  is  an  extra-peritoneal 
organ.  After  the  matter  has  been  evacuated,  search  may  be  made  in 
the  cavity  with  the  cannula  for  any  calculus  which  may  occupy  it. 
If  none  be  found  it  is  not  possible  to  state  that  the  disease  is  not  of 
calculous  origin  ;  nor,  if  calculous  matter  be  found,  can  the  converse 
of  this  proposition  be  affirmed  with  absolute  certainty.  In  Dr.  Pe- 
ters's  case  *  the  abscess  was  punctured  with  the  aspirator,  pus  evacu- 
ated, and  finally,  on  withdrawing  the  instrument,  a  fragment  of 
stone  was  found  impacted  in  its  extremity  ;  yet,  after  the  kidney  had 
been  extracted,  the  case  proved  to  be  one  not  of  calculous  pyelitis,  but 
of  inflammatory  (cheesy)  pyelonephritis.  The  patient  had  pseudo- 
tubercular  epididymitis,  with  fistula,  and  pseudo-tubercle  of  both  vasa 
deferentia  and  vesiculse  seminales.  As  a  rule,  however,  if  stony 
matter  can  be  felt,  calculous  pyelitis  may  be  safely  diagnosticated,  and 
an  operation  rationally  undertaken  for  its  relief.  If  no  stone  be  discov- 
ered, the  abscess  cavity  should  be  thoroughly  drained  and  the  patient 
allowed  to  rally.  Subsequently  nephrectomy  may  be  easily  performed 
if  thought  desirable  by  shelling  out  the  shriveled  remains  of  the  kid- 
ney. This  double  operation  is  considered  safer  by  modern  surgeons 
than  primary  nephrectomy  for  (strumous,  as  it  is  sometimes  called) 
suppurating  kidney. 

Extra-renal  abscess  should  always  be  opened  early,  even  if  no  at- 
tempt be  made  to  perforate  the  pelvis  of  the  kidney. 


HYDROITEPHROSIS. 

When  there  exists  an  obstruction  of  any  sort  in  the  ureter,  urine 
may  accumulate  and  gradually  distend  the  pelvis  of  the  kidney,  and 
lead  to  more  or  less  atrophy  of  kidney-substance.  This  is  hydrone- 
phrosis. It  may  be  caused  by  obstruction  to  the  free  outflow  of 
urine  in  the  bladder  or  urethra,  but  obstruction  in  the  ureter  is  greatly 
the  more  common  and  the  more  efficient  cause.  George  A.  Staples,  of 
Dubuque,  Iowa,  has  recently  made  an  excellent  study  of  this  condi- 
tion, and  compiled  tables  of  operations  upon  hydroneiDhrotic  kidneys, 
with  their  results.     The  hydronephrotic  kidney  sometimes  reaches  an 

*  "New  York  Medical  Journal,"  November,  1872. 


340  DISEASES  OF   THE   KIDNEY. 

enormous  size,  simulating  ascites  or  ovarian  cyst,  with  wliicli  maladies 
the  affection  has  boon  confounded  by  good  observers.  Koborts  *  quotes 
a  case  reported  by  (J lass,  in  which  thirty  gallons  of  light  coffee-colored 
limpid  fluid  were  taken  after  death  from  the  hydronei^hrotic  kidney 
of  a  young  woman.  The  motlier  stated  that  her  child  had  been  born 
dropsical.  Congenital  hydrono})hrosis  has  been  often  observed,  and 
has  been  reported  as  the  occasion  of  dystocia,  one  of  the  causes  being 
imperforate  urethra. 

Sometimes  the  cyst  is  smaller  than  tlie  healthy  kidney  (atrophy). 
Absorption  of  the  secreting  structure  is  usually  partial,  but  may  be 
complete.  One  or  both  kidneys  may  be  affected,  and,  what  is  remark- 
able, both  kidneys  may  be  largely  dilated,  and  display,  on  autopsy,  not 
a  trace  of  true  renal  structure,  and  yet  the  urine  jn-esent  nothing 
abnormal,  and  the  patient  live  in  this  condition  for  a  variable  length 
of  time.  In  such  cases  the  urine  is  usually  of  low  specific  gravity 
and  very  abundant,  and  death  may  occur  at  any  time  with  urajmic 
symptoms.  Infants  with  congenital  double  hydronephrosis  do  not 
live  (Kayer),  but,  where  the  affection  comes  on  gradually,  life  is  possi- 
ble to  a  far  greater  limit  than  would  seem  probable  a  priori.  It  is  pre- 
sumed that  the  skin  and  bowels  do  the  work  vicariously  in  these  cases 
for  the  kidneys.  The  fluid  of  hydronephrosis  is  generally  pale,  odor- 
less, limpid,  showing  no  albumen  on  the  application  of  heat  and  acid, 
and  leaving  very  little  residue  on  evaporation.  The  specific  gravity  is 
generally  very  low,  as  is  usually  the  case  in  urine  secreted  under 
pressure.  The  amount  of  urea  is  diminished.  A  careful  examination 
will  in  most  cases  detect  the  ordinary  ingredients  of  normal  very 
dilute  urine.  Sometimes  the  cysts  contain  a  colloidal  substance. 
Cholesterine  has  been  found  (Coghill). 

Causes. — Hydronephrosis  is  often  congenital,  depending  upon  an 
impervious  ureter,  or  some  valvular  obstruction  of  the  same.  Imper- 
vious (congenital)  urethra  may  be  the  cause  ;  later  in  life,  calculus 
impacted  in  the  ureter,  stricture  of  the  ureter  from  previous  ulcera- 
tion, pelvic  tumors,  ovarian  cysts,  or  other  body  (gravid  uterus)  com- 
pressing the  ureter.  Sometimes  no  mechanical  cause  can  be  assigned, 
except  a  valvular  fold  of  mucous  membrane,  or  great  obliquity  of  en- 
trance oi  ureter  into  pelvis  of  kidney,  acting  like  a  valve.  Morbid 
growths  within  the  bladdei*  may  lead  to  hydronephrosis,  or  cancer  of 
the  pelvic  organs,  uterus,  vagina,  and  rectum.  In  short,  any  obstruc- 
tive cause  may  lead  to  it.  Morris  narrates  a  number  of  cases  where 
an  unusual  cause  of  ol)struction  existed — such  as  local  injury  and  the 
contraction  resulting  therefrom,  abscess  of  the  fundus  of  the  bladder 
(Ebstein),  a  fibrous  band  across  the  ureter  (Simpson),  enlarged  lym- 
phatic glands  (Rayer),  frequency  of  urination  due  to  tight  prepuce 
(James),  compression  of  the  ureter  by  retained  menstrual  blood  in  one 

*  "Journal  of  the  American  Medical  Association,"  April  12  and  19,  1884. 


HYDRONEPHROSIS— SYMPTOMS.  341 

half  of  a  bifid  uterus  (Lagrave),  division  of  renal  artery,  one  branch 
of  which  compressed  the  ureter  (Boogard). 

(hurse. — The  obstacle  (possibly  calculus)  perhaps  becomes  dis- 
lodged in  time,  and  the  cyst  evacuated.  The  latter  may  not  refill ; 
its  sac  may  shrivel  up.  Finally,  ursemic  symptoms  may  carry  off  the 
patient,  but  many  die  of  intercurrent  disorders.  Spontaneous  rupture 
of  the  cyst  very  rarely  occurs.  Spencer  Wells*  punctured  a  dis- 
tended hydronephrotic  kidney  and  employed  drainage.  After  a  time 
two  calculi  passed  into  the  bladder,  and  the  hydronephrosis  got  well. 
John  W.  Taylor*  reports  a  case  of  acute  hydronephrosis  of  the  left 
kidney  in  which  rupture  of  the  sac  took  place,  the  urine  extravasating 
into  the  peritoneal  cavity.  The  abdomen  was  opened,  the  perito- 
naeum sponged  out  and  cleaned,  the  margins  of  the  sac  sewed  into 
the  abdominal  wound,  and  the  patient  recovered. 

Symptoms. — The  symptoms  of  hydronephrosis  depend  mainly 
upon  the  size  acquired  by  the  cyst,  and  the  compression  exerted  by  it 
upon  the  surrounding  organs.  If  the  tumor  be  small  and  the  other 
kidney  healthy,  no  symptom  during  life  may  lead  to  the  suspicion  of 
disease,  and  old  age  may  be  attained.  When  the  tumor  reaches  con- 
siderable size,  it  usually  presents  itself  in  the  flank,  extending  back- 
ward into  the  lumbar  region,  and  forward,  upward,  and  downward, 
to  a  greater  or  less  extent,  into  the  abdomen.  The  colon  usually  lies 
in  front,  the  small  intestines  being  pushed  to  the  opposite  side.  The 
tumor  is  flat  on  percussion,  feels  soft,  perhaps  lobulated,  and  is  evi- 
dently fluctuating.  Sometimes  the  tumor  suddenly  disappears  coinci- 
dently  with  a  free  discharge  of  urine.  This  syipiptom,  when  present, 
is  of  the  highest  diagnostic  value.  Pain  is  usually  absent,  unless 
there  be  at  the  same  time  impacted  calculus  in  the  ureter.  The 
action  of  the  bowels  may  be  irregular,  dysenteric  or  diarrhoeal,  from 
compression  of  the  large  intestine.  The  urine  presents  no  characters 
pathognomonic  of  the  disease.  It  may  be  absolutely  normal,  and  is 
not  necessarily  increased  in  quantity.  The  affection  occurs  about 
twice  as  frequently  in  the  female  as  in  the  male  (Morris).  There 
may  be  pain  in  the  back,  thirst,  irritable  bladder,  partial  anuria,  per- 
hai^s  intermittent,  abdominal  pain,  all  symptoms  due  to  obstruction 
and  occurring  sometimes  without  obvious  tumor.  Uraemia  may  occur 
if  the  affection  is  bilateral — constipation,  vomiting,  fever,  even  coma. 
Pain  is  sometimes  excruciating  ;  sometimes  there  is  no  pain. 

The  diagnosis  in  man  is  with  ascites,  hydatid  cysts,  and  pyone- 
phrosis. In  hydi-onephrosis  the  colon  lies  in  front  of  the  tumor ; 
there  is  no  resonant  percussion  in  the  lumbar  region  of  the  affected 
side,  but  it  exists  on  the  other  side,  unless  the  disease  be  double. 
No  change  in   the  patient's  position  affects  the  sounds.     In  ascites, 

*  "  British  Medical  Journal,"  April  29,  1876. 
f  "  Lancet,"  October  4,  ISS-i,  p.  589. 


342  DISEASES  OF  THE   KIDNEY. 

tlie  Innibar  dullness  is  double,  but  the  sounds  change  with  the  posi- 
tion of  the  patient.  In  hydatid  cyst  there  is  escape  of  hydatid  vesi- 
cles with  the  urine,  or  the  presence  of  hydatid  fremitus.  Hydatid 
cyst  is  less  often  double  than  hydroncphro;;is.  In  pyonephrosis 
there  is  or  has  been  pus  in  the  urine  ;  the  symptoms  are  more  severe, 
pain  is  prominent,  rigors  are  common.  A  ditlorcutial  diagnosis  with 
ovarian  cysts  seems  sometimes  to  be  impossible  without  exploratory 
incision. 

Treat  nun  f. — The  disease,  not  being  as  a  rule  very  dangerous  to  life, 
does  not  call  for  officious  surgery.  If  it  be  presumed  that  there  is  a 
calculus  impacted  in  the  ureter,  precautions  should  be  taken  to  prevent 
a  similar  accident  on  the  opposite  side.  Koberts  believes  that  be  was 
successful  in  one  case  in  overcoming  the  obstruction  jicrmanently  by 
manipulation.  A  little  girl  of  eight,  iinder  his  care,  had  a  soft,  fluctu- 
ating tumor  on  the  left  side  of  the  abdomen,  about  the  size  of  a  child's 
head,  which  was  believed  to  be  hydronephrosis.  This  was  carefully 
manipulated  in  every  direction  by  the  aid  of  a  lubricating  ointment  on 
alternate  mornings.  After  the  third  manipulation  a  large  quantity 
of  urine  Avas  suddenly  discharged  through  the  natural  channels,  the 
tumor  disappeared,  and  did  not  return  while  the  patient  was  under  ob- 
servation. Broadbent  had  a  similar  case  and  Thurman  another  (Mor- 
ris). But  manipulation  may  be  impossible  on  account  of  pain  and 
dangerous,  for  a  thin- walled  cyst  might  be  ruptured.  If  the  tumor 
becomes  troublesome  by  its  size,  interferes  with  the  intestinal  func- 
tions, or  shows  signs  of  inflaming,  aspiration  is  a  proper  treatment. 
The  needle  should  be  entered  in  front  of  the  eleventh  intercostal  space 
on  the  left  side,  unless  there  is  some  thin  or  bulging  point  elsewhere, 
which  manifestly  invites  puncture.  On  the  right  side  the  point  of 
election  is  ''half  way  between  the  last  rib  and  the  crest  of  the  jlium, 
between  two  inches  and  two  inches  and  a  half  behind  the  anterior  su- 
perior spine  of  the  ilium  "  (Morris).  Aspiration  sometimes  efifects 
cure  by  relieving  pressure  or  letting  a  bent  ureter  unfold.  Croft 
tapped  a  case  (occurring  after  a  traumatism)  eight  times  in  three 
months,  getting  several  pints  each  time,  and  a  cure  followed,  Morris 
thinks  the  obstruction  in  this  case  was  due  to  clot.  liecovery  after 
single  puncture  is  not  common,  but  has  been  noted.  Injection  of 
irritating  substances  has  been  resorted  to  when  simple  puncture  has 
failed.  Morris  condemns  the  method,  and  says  that  he  knows  of  no 
case  m  which  the  practice  has  been  successful ;  yet  Woelfler*  has  re- 
corded one  case  where  Billroth  punc':ured  an  immense  hydronephrotic 
tumor  in  a  boy  of  thirteen,  drawing  off  1,900  c.  c,  and  tapping 
through  the  abdomen  as  for  ascites.  Urinary  constituents  were  dis- 
covered in  the  fluid.  The  tumor  recurred,  and  seven  weeks  afterward 
was  again  punctured,  and  twenty-four  grammes  of  Austrian  tincture 

*  "Wiener  med.  Wochcnscbrift,"  No.  10,  1876,  p.  366. 


CYSTS.  343 

of  iodine  injected  with  an  equal  quantity  of  water  and  allowed  to  re- 
main in  five  minutes,  then  partly  withdrawn.  The  injection  was  re- 
peated in  three  months,  and  the  patient  is  recorded  as  dismissed  cured 
four  months  later. 

The  sac  may  inflame  and  suppurate  after  tapping.  In  such  case, 
or  should  aspiration  fail  to  cure,  the  next  ai:)propriate  expedient  is 
nephrotomy,  stitching  the  edges  of  the  incised  cyst-wall  into  the  loin. 
The  lumbar  incision  for  nephrotomy  is  made  high  and  carried  well 
forward,  the  cyst  exposed  and  punctured,  the  puncture  enlarged  with 
a  bistoury,  and  the  edges  of  the  incision  sewed  into  the  edges  of  the 
wound  in  the  loin.  A  large  rubber  tube  is  to  be  retained  in  the  cyst, 
and  daily  antiseptic  irrigation  practiced.  Staples,  in  his  excellent 
monograph,  records  seventeen  cases  successfully  treated  by  this  meth- 
od, although  permanent  fistula  remained  in  more  than  half  the  cases. 
When  fistula  remains,  its  annoyance  may  be  moderated  by-wearing  a 
large  rubber  tube  in  the  fistula,  which  expands  below  into  a  light  rub- 
ber bag,  attached  to  the  abdomen  by  a  belt.  After  nephrotomy,  an 
attempt  should  be  made  to  find  and  remove  impacted  calculus. 
Nephrectomy  is  only  called  for  when  the  sac  after  drainage  suppu- 
rates offensively.     The  operation  in  such  case  should  be  lumbar. 


KIDNEY-CYSTS. 

Several  forms  of  cysts  are  found  in  the  kidneys. 

Simple  cysts  by  occlusion  in  the  healthy,  or  more  often  the  granular 
kidney,  rarely  large  enough  to  occasion  aj)preciable  symptoms  during 
life.  Complete  cystic  degeneration  of  the  kidneys,  congenital,  and  oc- 
curring very  rarely  in  adult  life,  almost  invariably  affecting  both  kid- 
neys, and  necessarily  fatal.* 

Of  the  entozoa  found  in  the  kidney,  hydatid  cysts  only  come  under 
the  surgeon's  notice.  They  are  not  as  common  as  hydatids  of  the  liver 
or  lungs,  but  are  more  frequent  than  hydatids  of  other  parts  of  the 
body.  Space  will  not  allow  a  description  here  of  the  history  and  hab- 
its of  this  interesting  entozoon. 

Both  kidneys  are  rarely  involved  in  hydatid  disease  ;  the  left  seems 
to  suffer  more  frequently  than  the  right.  The  cyst  may  be  primarily 
lodged  in  any  portion  of  the  kidney-substance,  which  it  gradually  de- 
stroys by  pressure  as  it  grows.  It  forms  a  rounded,  elastic  tumor,  and 
may  reach  the  size  of  an  adult  head.  The  cyst  tends  to  point  inward, 
and  burst  into  the  pelvis  of  the  kidney,  but  may  grow  to  a  large  size 

*  In  a  practical  work  covering  as  mnch  ground  as  does  the  present,  it  is  impossible 
to  more  than  indicate  the  existence  of  this  rare  form  of  disease,  although  it  naturally 
falls  within  the  domain  of  surgery.  It  is  very  rarely  encountered,  and  totally  unamena- 
ble to  treatment.  For  its  study  the  reader  is  referred  to  text-books  on  renal  disease  and 
pathological  works,  in  which  it  forms  interesting  chapters. 


344  DISEASES  OF  THE  KIDNEY. 

without  so  doing,  and  eventually  discharge  into  the  intestines  or  the 
lungs.  Kidney  hydatid  cysts  have  not  been  known  to  discharge  into 
the  peritoneal  cavity,  or  externally  through  the  integument.  The 
cyst  may  inilame,  or  excite  abscess  in  its  vicinity  ;  the  echinococci  may 
die,  and  the  cyst  shrink  and  be  transformed  into  a  calcareous  mass, 
either  before  or  after  bursting.  The  cyst  may  be  ruptured  by  external 
violence. 

Sytnpfom-'i. — Until  the  C3'st  grows  large  enough  to  be  felt  or  seen  in 
the  flank,  there  are  usually  no  symptoms.  Febrile  attacks,  with  rigors 
and  pain,  are  occasioned,  if  the  cyst  or  its  neighborhood  inilame  or 
suppurate.  The  only  pathognomonic  symptoms  are  the  hydatid 
fremitus  on  palpation,  and  the  appearance  of  the  characteristic  vesicles, 
laminated  shreds,  or  booklets,  in  the  urine.  The  hydatid  fremitus  is 
rarely  perceived.  It  may  sometimes  be  obtained  by  grasping  the  tu- 
mor with  one  hand  and  tapping  the  fingers  sharply  with  the  other 
hand  ;  or  by  applying  a  stethoscope  over  the  tumor  while  the  latter  is 
tapped  smartly  with  the  fingers.  The  sensation  is  a  sort  of  a  creaking 
vibration  or  thrill  communicated  to  the  fingers,  and  has  been  com- 
pared to  the  vibrations  of  a  repeater  watch  held  in  the  hand.  The 
discharge  of  characteristic  vesicles  by  the  urethra,  when  a  cyst  has 
burst,  is  usually  spread  over  a  considerable  length  of  time,  the  dis- 
charges occurring  in  paroxysms,  occasionally  with  an  interval  of 
years  ;  if  there  is  only  one  small  cyst,  it  may  empty  itself  in  one 
paroxysm.  These  paroxysms  usually  begin  with  pain  in  the  back, 
followed  by  nephritic  colic  as  the  vesicles  pass  into  the  bladder,  and 
perhaps  retention  of  urine  and  considerable  pain  as  the  larger  vesi- 
cles traverse  the  urethra.  The  urine  usually,  at  such  times,  contains 
blood  and  pus,  and  there  are  symptoms  of  mild  cystitis  of  the  neck  of 
the  bladder.  The  tumor  in  the  flank  may  become  smaller  after  such 
an  attack,  from  a  discharge  of  some  of  its  contents,  or  increase  in  size 
by  distention  with  urine,  if  a  vesicle  be  retained  for  a  time  in  the  ure- 
ter. The  disease  is  most  liable  to  be  confounded  with  hydronephro- 
sis, in  case  no  vesicles  appear  in  the  urine. 

Prognosis. — The  natural  tendency  of  the  disease  is  to  get  well  by 
a  discharge  of  the  echinococci  through  tlie  ureter.  The  mortality  is 
lower  than  for  hydatids  of  any  other  internal  organ  except  the  uterus. 
Where  the  cysts  discharge  by  other  routes,  or  become  inflamed  and 
suppurate,  a  fatal  result  is  to  be  feared,  although  even  in  such  cases 
recovery  is  possible. 

Treatment. — Medicines  are  of  no  avail  before  the  cyst  has  opened 
into  the  pelvis  of  the  kidney.  Niter,  coffee,  white  wine,  spirits,  and, 
in  general,  diuretics,  have  sometimes  been  found  to  increase  the  quan- 
tity of  hydatids  appearing  in  the  urine  after  the  opening  of  a  cyst.  If 
the  cyst  attain  a  large  size,  and  do  not  burst  into  the  pelvis  of  the 
kidney,  the  proper  surgical  treatment  is  lumbar  nephrotomy,  the  sides 


TUBERCLE.  345 

of  the  cyst  being  stitched  into  the  incision.  If  the  tumor  jirojects 
prominently  in  front,  or  is  adherent  there,  an  abdominal  incision  may 
be  preferable. 

TUBERCLE   OP   THE   KIDNEY. 

This  disease  occurs  in  two  forms — (1)  miliary  tubercle  and  (2) 
tubercular  pyelonephritis. 

1.  Miliary  tubercle  occurs  as  small  granulations  of  true  tubercle 
deposited  rapidly  in  acute  general  tuberculosis  and  occupying  the 
secreting  structure  and  pyramids.  The  little  nodules  are  deposited 
mainly  along  the  course  of  the  smaller  vessels.  This  species  is  only 
a  part  of  acute  miliary  tuberculosis.  It  rarely  furnishes  local  symp- 
toms, and  is  usually  discovered  after  death.  As  a  kidney  disease  it 
is  unimportant.  It  is  generally  bilateral,  and  occurs  chiefly  in  chil- 
dren under  ten  years  of  age.  The  testicle,  seminal  vesicle,  and  pros- 
tate may  be  involved. 

2.  Tuhercular  Pyelonephritis. — This  is  the  scrofulous  kidney,  the 
form  of  kidney  tuberculosis  which  may  be  diagnosticated  during  life. 
When  involving  only  one  kidney  it  may  remain  localized  for  years, 
finally  resulting  in  atrophy  of  the  kidney,  which  remains  as  a  larger 
or  smaller  encapsulated  cheesy  or  fibrous  mass,  or  it  may  go  on  to 
make  the  large,  cheesy,  tubercular  kidney  full  of  inspissated  pus,  pos- 
sibly attended  by  perinephritic  abscess,  opening  spontaneously  (if  al- 
lowed) in  the  flank,  groin,  or  intestine. 

Scrofulous  kidney  generally  commences  by  a  deposit  of  gray  tuber- 
cular matter  upon  the  papillae,  thence  passing  to  the  mucous  mem- 
brane of  the  calices.  The  gray  nodules  first  infiltrate  a  portion  of 
tissue,  then  undergo  a  cheesy  degeneration,  and  break  down  into  tu- 
bercular ulcers,  which  advance  inwardly,  destroying  everything  in  their 
course.  The  pelvis  and  ureter  participate  in  the  disease,  perhaps  pri- 
marily, but  certainly  in  the  course  of  time.  The  disease  is  compara- 
tively rare,  and  not  infrequently  coincides  with  the  deposit  of  tubercle 
elsewhere,  especially  in  some  other  portion  of  the  genito-urinary  appa- 
ratus (prostate,  epididymes,  seminal  vesicles).  All  ages  are  liable  to 
it,  but  it  is  most  common  in  early  manhood.  It  comes  on  usually  in 
an  insidious  manner.  The  little  tubercular  masses  unite  to  form  large 
patches.  Kidney-substance  is  absorbed,  to  be  replaced  by  the  lowly 
vitalized  tubercular  matter.  After-  a  while  the  masses  soften  centrally, 
break  down  into  a  puriform  matter,  and  leave  ragged  ulcers  in  the 
kidney-substance,  or  in  the  walls  of  the  pelvis.  Earely  these  ulcers  or 
abscesses  heal,  leaving  a  depressed  cicatrix.  Some  ulcerations  may 
cicatrize,  while  others  progress.  The  fibrous  structures  of  the  ureters 
and  pelves  of  the  kidneys  become  greatly  thickened  and  indurated  by 
chronic  inflammation,  so  that  the  caliber  of  the  ureter  may  be  nearly 
or, quite  obliterated.     The  ureter  so  constricted  mav  become  blocked 


346  DISEASES  OF  THE  KIDNEY. 

up  by  some  softened  tubercular  matter  or  tissue  debris,  coming  down 
fi'om  above,  in  which  case  pyonephrosis  would  in  all  probability  result, 
with  symptoms  of  nephritic  colic  at  the  beginning.  A  stone  formed 
in  the  kidney  may  be  unable  to  pass  the  contracted  ureter,  or,  from 
decomposition  of  the  urine  retained  in  the  kidney  in  contact  with  the 
tubercular  ulcerations,  phosphatic  stone  may  be  formed  there.  Under 
any  of  these  contingencies  the  symptoms  would  resemble  those  of 
chronic  calculous  pyelitis.  The  disease  is  more  frequently  double  than 
single.  Sometimes,  however,  it  is  found  on  one  side  only,  and  then 
it  not  unusually  happens  that  the  testicle  or  epididymis  of  the  same 
side  also  suffers.  There  is  an  undoubted  connection  in  the  male  sex 
between  tuberculization  of  the  genital  organs  and  that  of  the  kidney. 
The  attack  of  the  former  usually  precedes  that  of  the  latter,  and  seems 
to  hold  a  certain  causal  relation  to  it.  Instead  of  remaining  local,  the 
malady  may  involve  other  organs.  General  tuberculosis  may  exist 
with  it. 

Symptoms. — The  symjitoms  are  identical  with,  and  in  fact  are, 
those  of  chronic  pyelitis,  witii  or  without  severe  nephralgia  or  nephritic 
colic.  It  is  rare  that  much  or  any  pain  is  felt  at  first,  the  disease  most 
often  coming  on  insidiously.  There  are  exceptions  to  this  rule,  when, 
for  instance,  a  large,  acute  deposit  is  attended  by  great  local  pain, 
fever,  bloody  urine,  etc. 

If  pyonephrosis  comes  on,  the  tumor  or  sacculated  abscesses  may 
be  felt  in  the  flank.  As  the  disease  progresses  the  nephralgia  be- 
comes more  marked,  as  do  also  the  accompanying  symptoms  of  cystitis. 
Great  emaciation,  with  rigors  and  hectic  fever,  supervenes,  and  the 
patient  dies  exhausted,  or,  from  the  bursting  of  kidne3'-abscess,  possi- 
bly with  ursemic  symptoms,  or,  from  tubercular  disease  elsewhere, 
wasted  by  hectic.  There  is  rarely  any  profuse  hEematuria  with  kidney 
tuberculosis.  The  urine  is  almost  uniformly  over-acid.  The  disease 
may  prove  rapidly  fatal  in  a  few  months,  or  may  drag  along  many 
years. 

Diagnosis. — The  most  reliable  diagnostic  marks  of  this  affection 
are  chronic  pyelitis  coming  on  in  a  tubercular  subject,  or  one  of  tuber- 
cular antecedents,  or  living  in  bad  hygienic  surroundings,  where  no 
other  cause  (stone,  etc.)  for  the  pyelitis  is  evident.  Where  the  epididy- 
mis is  the  seat  of  cheesy  degeneration,  or,  the  seminal  vesicles  knotty 
with  chronic,  cheesy  deposit,  or  the  prostate  affected  by  similar  dis- 
ease, and  symptoms  of  chronic  pyelitis  come  on,  a  diagnosis  of  tuber- 
cular pyelitis  may  be  safely  ventured.  The  urine  usually  contains  a 
large  amount  of  debris  besides  its  pus,  but,  taken  by  itself  without  the 
evidence  furnished  by  other  symptoms,  this  sign  is  absolutely  value- 
less. The  bacillus  is  sometimes  found  by  careful  staining  of  tiie 
clumps  of  pus. 

Treatment. — Tubercular  disease  of  the  kidney  is  very  rarely  recov- 


CANCER.  347 

ered  from ;  it  is  even  more  fatal  than  tubercle  of  other  vital  organs. 
Its  treatment  is  that  of  chronic  pyelitis,  and  that  of  chronic  tubercu- 
losis— fatty  medicines  and  food,  proper  hygiene  in  air,  clothing,  and 
diet,  witli  quinine,  iron,  astringents,  and,  if  the  pain  be  great,  a  small 
amount  of  anodyne.  Eenal  and  extra-renal  accumulations  of  pus  may 
require  external  incision.  Extirpation  is  not  to  be  thought  of,  unless 
thGre  is  pretty  positive  evidence  that  one  kidney  is  sound,  in  which 
case  nephrotomy  is  the  proper  operation,  followed  later,  if  necessary, 
by  nephrectomy. 

A  question  of  the  first  importance  to  decide  in  these  cases  is  whether 
or  not  the  other  kidney  is  involved.  The  various  ingenious  means 
suggested,  such  as  Fenwick's*  suction  catheter,  Silberman's  f  com- 
pression bag,  for  closing  one  ureter  within  the  bladder  by  filling  the 
bag  with  mercury,  Lewer's  J  method  in  women,  by  using  one  half  of 
Bryant's  rectal  speculum  passed  through  a  dilated  urethra,  thus  com- 
pressing one  ureter  while  the  other  acts,  other  means  of  pressure  within 
the  bladder  upon  one  ureter,  several  of  which  have  been  suggested, 
Simon's  and  Winckel's  catheterism  of  the  ureter  in  the  female — none 
of  these  means  seem  practically  applicable.  A  negative  rough  diag- 
nosis may  be  made  by  the  absence  of  tumor  upon  the  side  supposed  to 
be  sound,  the  absence  of  pain  upon  this  side  subjective  or  called  out 
by  manipulation,  the  secretion  of  a  normal  amount  of  urine  contain- 
ing a  full  daily  quantity  of  urea.  Both  kidneys  are  implicated  as  often 
as  one  alone,  perhaps  more  often  ;  therefore  it  is  safer  first  to  resort  to 
nephrotomy,  leaving  nephrectomy  for  subsequent  performance,  if  called 
for  after  further  study  of  the  case. 

CANCER    OF    THE    KIDNEY. 

Cancer  of  the  kidney  is  not  a  common  disease.  It  occurs  primarily 
in  the  kidney  or  in  general  cancerous  cachexia  as  a  secondary  deposit, 
especially  secondary  to  cancerous  disease  of  other  parts  of  the  genito- 
urinary apparatus,  in  which  case  it  often  fails  to  furnish  any  symptoms, 
and  is  to  be  detected  only  by  autopsy.  Again,  secondary  cancer  of  the 
kidney  may  assume  primary  rank,  and  lead  to  the  fatal  issue  by  its  rapid 
growth.  Secondary  deposits  occurring  in  connection  with  cancer, 
other  than  of  the  genito-urinary  organs,  usually  afi;ect  both  kidneys  in 
the  shape  of  numerous  nodules,  from  the  smallest  imaginable  size  up 
to  that  of  a  nut  or  larger.  These  nodules  as  a  rule  occasion  no  renal 
or  vesical  symptom,  there  being  enough  tissue  left  to  perform  the 
function  of  the  kidney.  Their  softening  and  ulceration  may  not  have 
time  to  take  place,  on  account  of  the  more  advanced  condition  of  the 

*  "Lancet,"  September  IS,  1SS6,  p.  529. 
f  "Berliner  klin.  Wochensehrift,"  1S84. 
i  "Lancet,"  November  13,  1886,  p.  914. 


348  DISEASES  OF  THE  KIDNEY. 

primary  cancerous  deposit,  Avliich  carries  ofT  the  patient  by  cachexia 
or  otherwise. 

Cancer  of  the  kidney  is  ahnost  always  encephaloid  (soft);  scirrhous, 
colloid,  and  other  forms  being  mentioned  as  curiosities  in  surgery. 
No  time  of  life  is  exempt  from  an  attack  of  primary  cancer  of  the  kid- 
ney. Children  under  four  years  seem  especially  liable,  and  old  age 
the  next  most  frequent  epoch  for  its  appearance.  As  a  rule  only  one 
kidney  is  affected.  The  disease  may  advance  until  the  mass  has 
reached  a  size  large  enough  to  fill  the  whole  abdomen,  and  a  weight 
of  twenty  to  thirty  pounds.  It  always  seems  to  begin  in  the  cortical 
substance,  extending  thence  to  the  pyramids.  The  kidney-substance 
as  such  becomes  absolutely  obliterated,  no  trace  of  it  being  left  in  the 
large  cancerous  mass,  which,  like  other  sjiecimens  of  soft  cancer,  is 
usually  lobulated,  harder  in  some  parts  than  in  others,  of  different 
consistence  in  different  specimens,  giving  obscure  or  real  fluctuation 
in  parts,  often  containing  large  cavities  filled  with  clots,  fluid  blood,  or 
cancer  debris,  possibly  pus,  "a  strange,  distempered  mass"  (Ilcy). 
Cancer  of  the  kidney,  like  that  of  the  liver  and  testis,  is  commonly  filled 
with  numerous  large,  thin-walled  vessels  which  readily  break,  form- 
ing blood  cysts  and  clots  of  large  size.  Kidney-cancer  sometimes 
grows  out  through  the  renal  vein  and  advances  into  the  ascending 
cava.  Here  portions  of  it  may  be  broken  off  and  be  carried  along  in 
the  general  circulation  to  form  infarctions  in  the  lungs.  When  the 
cancerous  mass  sprouts  out  into  the  pelvis  of  the  kidney,  its  large, 
thin-walled  vessels  are  apt  to  give  way  and  occasion  that  symptom  so 
characteristic  of  cancer  —  profuse,  spontaneously  recurring  hemor- 
rhage, often  filling  the  bladder  to  distention  with  clots. 

The  disease  may  commence  as  a  single  cancerous  nodule,  or  as  an 
infiltration.  When  the  tumor  reaches  large  size,  it  usually  forms  in- 
flammatory adhesions  with  all  the  surrounding  viscera.  The  colon 
lies  in  front  of  it,  the  other  viscera  are  crowded  aside.  The  pressure 
of  the  cancerous  mass  may  cause  caries  of  the  vertebra.  The  ureter 
is  often  occluded.  When  the  disease  in  the  kidney  is  primary,  second- 
ary deposits  are  apt  to  occur  in  the  rest  of  the  body.  The  lymphatic 
glands  in  the  hilum  of  the  kidney  and  the  vertebral  and  mesenteric 
glands  are  often  involved,  sometimes  forming  a  considerable  tumor 
of  themselves.  Sometimes  the  primary  seat  of  the  cancerous  growth 
is  in  the  lymphatic  glands  or  other  tissues  about  the  hilum,  whence, 
spreading,  the  kidney  becomes  implicated.  Maxon  thinks  that  this  is 
the  commonest  method  of  onset  of  primary  renal  cancer. 

Symptoms. — The  most  constant  symptom  of  primary  renal  cancer 
is  a  tumor,  which  sometimes  in  adults,  more  often  in  children,  attains 
enormous  proportions  before  death.  This  tumor  is  first  noticed  in  the 
flank  above  the  crest  of  the  ilium,  growing  forward  and  upward.  It 
usually  feels  irregular  but  smooth  (lobulated),  and  sometimes  gives  the 


CANCER. 


349 


sensation  of  clcop  fluctuation  at  points.  It  may  be  entirely  painless 
to  pressure.  The  resonance  of  the  colon  passing  in  front  of  it  may 
often  be  made  out.  Pain  in  the  back  and  hypocliondrium,  in  the  re- 
gion of  the  Icidney,  of  the  nephralgic  character,  is  usually  complained 
of  before  the  tumor  appears,  perhaps  not  till  later.  The  pain  is  usu- 
ally intermittent  in  character,  and  not  often  very  intense.  It  may 
be  wholly  absent.  Hajmaturia  is  a  sign  of  great  value  when  present, 
but  its  absence  has  not  the  signification  which  has  been  given  to  it. 
It  may  be  absent  throughout  the  disease,  or  appear  for  a  time  only  at 
the  beginning  or  at 
the  end.  It  is  rarely 
continuous  through- 
out, tending,  as  it 
does,  to  be  irregularly 
intermittent  without 
appreciable  cause. 
Often  during  the 
paroxysms  it  is  very 
profuse,  perhaps  clot- 
ting in  the  ureter  or 
bladder,  aiid  causing 
considerable  incon- 
venience and  pain. 
If  distressing  feelings 
have  been  present, 
some  alleviation  of 
them  is  apt  to  fol- 
low profuse  bleeding. 
When  h^ematuria  is 
abundant  and  parox- 
ysmal without  provo- 
cation, in  the  case  of 
renal  tumor,  cancer 
should  be  suspected. 
Vesical  irritability 
may  be  the  only  pro- 
nounced symptom, 
leading  the  careless  observer  to  overlook  the  kidney  and  to  search  for 
the  seat  of  the  disease  in  the  bladder. 

Among  other  symptoms  there  may  be  ascites,  anasarca,  and  great 
development  of  the  cutaneous  abdominal  veins,  from  pressure  of  the 
tumor  upon  the  large  venous  trunks  within  the  abdomen.  The  size 
of  the  tumor  may  cause  functional  derangements  of  the  stomach  and 
bowels.  Vomiting  sometimes  appears  early.  The  urine  presents  no 
characteristic  diagnostic  features.      It  is  idle  to  place  any  reliance 


Fig.  104  (Roberts). 


350  DISEASES  OF  THE   KIDNEY. 

Tipon  the  appearance  of  so-called  cancer-cells  in  the  urine,  or  upon 
tlie  hope  of  finding  a  shred  of  cancer-tissue,  since  such  a  shred,  start- 
ing at  the  kidney,  already  softened  and  partly  decomposed  by  iho. 
ulcerative  process  which  loosened  it,  would  become  wholly  indistin- 
guishable asa  portion  of  cancer  after  traversing  the  ureter  and  remain- 
iucr  soaked  in  urine  in  the  bladder  for  even  a  short  time.  In  children 
the  disease  is  more  rapidly  fatal  than  in  tiie  adult.  It  rarely  lasts 
over  a  year.  The  tumor  grows  to  an  immense  size,  not  infrequently 
lining  the  whole  abdomen.     The  patient  emaciates  rapidly  and  dies. 

Fig.  104  is  an  excellent  representation  of  a  child  with  advanced 
cancer  of  the  kidney.     It  is  rather  too  extreme  to  be  typical. 

Adults  with  cancerous  kidney  usually  die  in  two  or  three  years, 
but  many  drag  out  more  than  double  that  length  of  time  (Roberts). 
Cancerous  cachexia  is  more  liable  to  be  marked  in  the  adult  than  in 
the  child. 

TJie  diagnosis  in  the  male  is  with  ascites,  hepatic  or  splenic  tumor, 
or  renal  tumor  of  other  nature  (hydronephrosis,  pyonephrosis,  hyda- 
tid). In  ascites  fluctuation  is  distinct,  both  loins  are  flat,  the  dull- 
ness may  be  made  to  change  by  position.  A  kidney-tumor  is  im- 
movable, feels  solid  in  parts,  only  one  flank  is  flat  on  percussion.  A 
tumor  in  connection  with  the  liver  does  not  have  the  colon  in  front  of 
it.  A  kidney-tumor  can  usually  be  separated  from  the  liver  unless 
adhesions  have  formed  ;  perhaps  a  line  of  resonance  will  exist  between 
them.  A  splenic  tumor  does  not  have  the  colon  in  front ;  it  grows 
more  upward  than  downward  ;  resonance  may  be  heard  in  the  flank 
behind  it ;  its  border  may  be  felt  stiff  and  thinnish  ;  deep  percussion 
will  elicit  the  bowel-sound  beneath  (for  the  spleen  is  not  a  very  thick 
organ)  ;  the  history  will  show  previous  malarial  poisoning. 

For  diagnosis  with  other  renal  tumors,  the  previous  history,  pres- 
ence or  absence  of  cachexia,  existence  of  pus  or  hydatids  in  the  urine, 
sudden  decrease  of  the  tumor  after  free  urination,  etc.,  form  the  dis- 
tinguishing points. 

Treatment. — The  hasmaturia,  if  excessive,  calls  for  treatment,  as 
may  also  the  nephralgia.  As  the  disease  is  so  often  confined  to  one 
kidney  for  a  length  of  time,  without  infecting  neighboring  glands  or 
other  parts,  if  the  case  is  recognized  early,  nephrectomy  is  the  proper 
treatment. 

OTHER    TUMORS    IN    THE    KIDNEY. 

Many  other  forms  of  tnmor  occur  in  the  kidney,  such  as  myo- 
sarcoma, adenoma,  cavernous  angeioma,  lymphadenoma,  villous  papil- 
loma, syphilitic  gummata.  The  villous  growth  yields  hasmorrhage  ; 
some  of  the  others  do  the  same,  others  not.  A  diagnosis  is  difficult 
even  when  a  tumor  can  be  felt.  Treatment  is  palliative,  with  extir- 
pation reserved  for  the  cases  which  seem  to  justify  it. 


NEPEKOTOMY— NEPHRECTOMY.  351 


NEPHROTOMY. 


A  slightly  oblique  inciyion,  three  and  a  half  to  four  inches  long,  i., 
made  from  behind  forward  ici  the  ilio-costal  space,  commencing  over 
the  outer  edge  of  the  erector  spinas  muscle.  The  incision  is  about  tlic 
same  as  the  oblique  incision  for  lumbar  colotomy.  After  dividing 
the  deep  fascia  and  all  the  muscular  structures  in  the  line  of  the  in- 
cision, keeping  the  posterior  part  of  the  wound  the  deepest,  the  edge 
of  the  quadratus  lumborum  will  be  seen,  and  may  be  divided  if  broad 
and  in  the  way.  The  deep  lumbar  aponeurosis  is  cut  through,  and 
then  the  deep  fat  around  the  kidney  is  come  upon,  perhaps  consider- 
ably condensed  and  modified  by  inflammatory  changes.  The  abscess 
of  the  kidney  or  cyst  for  which  nephrotomy  is  being  performed  is 
reached  by  cutting  or  tearing  through  the  condensed  fat,  is  then 
punctured  and  freely  opened  with  the  knife  or  Paquelin  cautery,  the 
finger  introduced  into  the  pelvis  of  the  kidney  to  break  down  parti- 
tions and  search  for  stone.  Then  the  cyst  or  abscess  wall  may  be 
sewed  into  the  abdominal  wound  with  silk,  small  drainage-tubes  be- 
ing left  outside  between  the  cyst- wall  and  the  fresh  wound  if  required, 
or  a  large  drainage-tube  may  be  inserted  into  the  kidney  and  the 
wound  partially  sutured,  especially  the  front  part  of  the  superficial 
incision. 

The  operation  is  not  a  serious  one.  I  have  performed  it  several 
times  upon  the  more  damaged  of  two  suppurating  kidneys  when  both 
were  diseased,  and  have  always  seen  the  patient  rally  well  and  find  re- 
lief. If  the  ureter  is  obliterated  and  enough  kidney  substance  left  to 
secrete  urine,  permanent  fistula  remains.  A  flat  rubber  bag  fitted  to 
the  loin  and  connected  with  a  drainage-tube  inserted  into  the  fistula 
makes  this  condition  bearable  by  the  patient.  If  the  abscess  does  not 
get  well,  and  pus  continues  to  be  abundantly  secreted,  nephrectomy 
may  be  subsequently  called  for  to  save  the  patient  from  exhaustion. 

NEPHRECTOMY. 

Nephrectomy  is  the  entire  removal  of  the  kidney  by  a  cutting  oper- 
ation. There  are  two  recognized  operations,  the  lumbar  and  the  ab- 
dominal. Lumbar  nephrectomy  is  usually  preferred.  The  perito- 
ngeum  is  not  opened,  and  natural  drainage  is  easily  effected  on  account 
of  the  posterior  and  therefore  dependent  position  of  the  wound.  It 
is  the  only  operation  usually  allowable  after  previous  nephrotomy 
when  the  latter  operation  has  not  effected  a  cure,  but  has  left  a  disor- 
ganized suppurating  kidney  which  fails  to  get  well  under  drainage. 
For  stone  in  the  kidney  when  nephrolithotomy  is  not  applicable, 
lumbar  nephrectomy  is  the  projDcr  operation,  as  it  is  also  for  rupture 
or  wounds  of  the  kidney  or  ureter  when  the  case  is  sufficiently  severe 


352  DISEASES  OF  THE   KIDNEY. 

to  demand  more  than  palliaiivo  nioasuros  or  draiiiaqo.  For  cysts  and 
small  tumors,  tlie  lumbar  operation  is  also  preferable,  and  for  very 
l)ainful  iloating  kidney  when  neplirorraphy  will  not  answer. 

Abdominal  nephrectomy  is  called  for  when  the  diseased  kidney  is 
very  large  or  nuicli  displaced  downward,  and  in  most  cases  of  cancer 
when  any  operation  is  allowable. 

Nephrectomy  should  not  be  performed  until  all  other  means  of 
relief  are  exhausted,  and  when  life  is  seriously  threatened  either  imme- 
diately or  remotely.  A  patient  with  only  one  kidney  to  rely  upon  is 
always  in  more  serious  danger  from  the  occuri-enco  of  any  kidney  dis- 
ease than  if  he  had  two  organs,  although  one  of  them  nniy  be  structur- 
ally unsound. 

Lumbar  Xcpltrcrtomij. — A  transverse  incision,  running  in  a  slightly 
oblique  direction  downward  and  forward,  is  made  in  the  ilio-costal 
space,  about  four  inches  long,  and  never  nearer  than  half  an  inch  to 
the  twelfth  rib,  for  fear  of  opening  the  pleura,  which  sometimes  de- 
scends below  the  rib.  A  second  liberating  incision  may  be  made  if 
necessary  vertically  downward,  starting  near  the  posterior  extremity  of 
the  first  incision.  This  second  incision  may  not  be  needed,  and  may 
be  left  until  after  the  kidney  has  been  exposed  and  employed  if  re- 
quired to  make  more  room  for  getting  at  the  pedicle. 

When  the  capsule  of  the  kidney  is  reached,  by  tearing  through  its 
fatty  envelope,  if  there  has  been  little  or  no  previous  inflammation 
around  the  kidney,  the  organ  may  be  separated  with  its  capsule  from 
the  surrounding  parts  by  a  careful  use  of  the  finger.  If  there  has 
been  much  perirenal  inflammation — notably  in  cases  of  the  so-called 
scrofulous  kidney,  and  after  previous  nephrotomy — the  kidney  proj^er 
must  be  shelled  out  from  its  own  thickened  capsule,  which  latter  is 
usually  firmly  attached  to  the  surrounding  parts. 

The  pedicle  is  secured  by  passing  a  strong  double-silk  ligature  with 
a  long  aneurism  needle  between  the  ureter  and  the  vessels.  The  lat- 
ter are  ligated  in  mass,  the  other  half  of  the  double  ligature  being  em- 
plo3'ed  to  secure  the  ureter.  The  ligatures  should  be  placed  as  deeply 
as  possible.  The  kidney  may  now  be  drawn  out  of  the  wound  by 
forcibly  elevating  the  twelfth  rib,  another  ligature  is  thrown  around 
the  entire  pedicle  close  to  the  kidney,  including  the  ureter,  and  between 
this  and  the  other  two  ligatures  the  pedicle  is  carefully  snipped  away 
with  blunt  curved  scissors. 

All  bleeding  points  in  the  wound  must  now  be  carefully  secured 
with  ligature,  all  the  ligatures  cut  sliort,  and  the  pedicle  dropped  into 
the  wound.  xVntiseptic  irrigation  should  be  employed  and  a  large 
drainage-tube  used,  the  wound  being  brought  together  with  deep  and 
superficial  sutures  and  treated  antiscptically  as  to  its  dressings.  The 
drainage-tube  should  be  kept  in  a  short  week,  and  then  be  removed  by 
being  gradually  shortened  from  day  to  day  and  made  smaller.     The 


SYPUILTTIC   KIDNEY.  353 

wound  requires  about  a  month  to  close,  and  meantime  the  patient 
should  bo  kept  very  quiet,  being  fed  sparingly  both  as  to  food  and 
drink. 

If  the  lumbar  space  is  too  small  to  allow  removal  of  the  kidney,  ex- 
cision of  the  last  rib  has  been  advised.  This  is  of  very  doubtful  pro- 
priety. It  is  better  in  such  cases  to  have  recourse  to  the  abdominal 
operation.  If  the  colon  or  peritonaeum  be  opened,  they  should  be 
sutured  at  once.  If  the  pedicle  bleeds  and  can  not  be  successfully 
ligated,  a  clamp  should  be  placed  upon  the  bleeding  points  and  allowed 
to  remain  in  the  wound. 

Abdominal  Nephrectomy. — The  incision  generally  adopted  is  along 
the  outer  border  of  the  rectus  muscle  on  the  side  of  the  kidney  to  be 
removed.  Before  the  peritonaeum  is  opened,  all  bleeding  must  be 
arrested.  When  the  abdomen  is  open,  the  clean  and  disinfected  hand 
is  passed  into  the  peritoneal  cavity  to  explore  the  other  kidney.  If 
this  is  found  to  be  sound,  the  operation  is  continued,  otherwise  it 
should  be  given  up.  The  intestines  are  kept  out  of  the  way  as  usual 
with  large,  flat,  clean,  disinfected  abdominal  sponges.  The  outer 
layer  of  the  meso-colon  should  now  be  opened  sufficiently  to  allow 
three  fingers  to  be  introduced.  With  the  fingers  the  fat  should  be 
separated  and  the  renal  vessels  sought.  They  are  to  be  tied  in  mass 
with  strong  disinfected  silk.  The  ureter  should  then  be  seized  with 
two  pinch  forceps  and  tied  between  with  silk.  It  may  be  stitched 
into  the  wound  if  it  contains  pus.  Another  ligature  may  now  be 
thrown  about  the  vessels  nearer  the  kidney,  if  there  is  room,  and  the 
pedicle  divided  between  the  ligatures.  The  kidney  is  now  to  be  enu- 
cleated and  carefully  removed.  The  wound  should  be  carefully  irri- 
gated and  sponged  with  hot  water  or  Thiersch  solution,  the  peritoneum 
sewed  up  with  catgut,  if  thought  necessary,  a  hard  rubber  or  glass 
drainage-tube  passed  to  the  bottom  of  the  wound,  and  the  abdominal 
incision  sewed  up  as  after  ovariotomy  with  deep  and  superficial 
sutures.  Antiseptic  dressings  are  applied.  The  bottom  of  the  drain- 
age-tube is  to  be  sucked  out  hourly  at  first,  then  at  longer  intervals,  by 
a  trained  nurse  or  skilled  assistant,  with  any  form  of  suction-tube  or 
long-nozzled  syringe.  After  twenty-four  or  forty-eight  hours,  the 
tube  may  usually  be  removed.  If  thought  better,  it  may  remain  longer. 
The  patient  must  get  up  slowly  and  wear  an  abdominal  bandage  for 
many  months. 

SYPHILIS   OF   THE   KIDNEY. 

Syphilitic  disease  of  the  kidney  is  not  common.  Lancereaux,*  in 
24  autopsies  of  patients  affected  with  visceral  syphilis,  found  the  kidney 
involved  in  8.      Moxon  f  was  more  fortunate,  finding  changes  j^ost 

*  "Gaz.  Hebd.,"  i,  1864,  p.  502. 
t  "  Guy's  Hospital  Reports,"  1868,  p.  329. 
23 


354  DISEASES  OF  THE   KIDNEY. 

mortem  in  14  out  of  25.  Vircliow*  believes  that  am3'loid  degenera- 
tion of  the  kidneys  may  depend  directly  upon  sy])hilitic  cachexia. 
E.  Wagner.f  in  0,000  autoi)sies,  found  G3  cases  of  kidney  trouble  in 
syphilitics,  of  which  35  were  amyloid,  3  only  were  syphiloma,  the  rest 
inllammatory  changes.  Speiss,  J  in  320  syphilitic  autopsies,  found  7 
cases  of  gummatous  nephritis  and  140  damaged  kidneys,  not  obviously 
syphilitic.  Bamberger,*  in  1,460  cases  of  Bright's  disease,  acute  and 
chronic,  found  syphilis  in  49  cases.  The  syi)hilitie  nature  of  larda- 
ceous  degeneration  was  first  described  by  Kaycr  ||  in  1840.  lie  also 
notes  other  forms  of  syphilis  of  the  kidney.  Hans  Ilebra-^  reports  an 
excellent  case  of  syphilitic  paraj^legia  cured  by  treatment.  About  a 
month  after  recovery  the  patient  returned  with  swollen  legs  and  in- 
tense albuminuria,  which  disappeared  promptly  undrr  large  doses  of 
the  iodide  of  potassium. 

Syphilitic  disease  of  the  kidney  is  relatively  more  common  in  the 
infant  who  dies  of  inherited  disease  than  in  the  adult  with  acquired 
syphilis. 

Albuminuria  has  been  quite  often  noticed  in  the  early  exantliema- 
tous  stage  of  syphilis.  Lancercaux  thinks  that  prolonged  mercurial 
treatment  may  have  something  to  do  with  this  in  an  etiological  way. 
Hardy  believes  it  due  to  the  debilitating  influence  of  the  virus  directly. 
Certain  it  is  that  the  albumen  sometimes  appears  in  cases  which  have 
taken  no  mercury,  and  equally  certain  is  it  that  it  often  disappears 
under  the  continued  use  of  mercury.  This  I  have  verified  more  than 
once.  In  many  instances,  again,  albumen  wmII  disappear  totally,  to- 
gether with  the  symptoms  which  accompany  it,  if  iodide  of  potassium 
i?  freely  given.  This,  also,  I  have  more  than  once  observed  in  a  man- 
ner so  definite  and  striking  that  I  do  not  hesitate  to  make  a  general 
statement  of  the  fact.  My  note-books  possess  the  cases.  But,  on  the 
other  hand,  it  will  occasionally  happen  that  patients  with  visceral 
syphilis,  under  protracted  treatment  by  large  doses  of  iodide  of  potas- 
sium, will  gradually  show  morning  nausea,  and  upon  examination 
their  urine  will  be  found  light,  slightly  albuminous,  and  containing 
pale  casts.  In  such  cases  the  kidney-trouble  is  probably  due  to  the 
irritation  produced  by  the  large  amount  of  iodide  of  potassium  passing 
through  them,  and  the  albumen  and  casts  may  be  made  to  disappear, 
together  with  the  morning  nausea,  by  reducing  the  activity  of  the 
treatment.  Several  such  cases  have  fallen  under  the  author's  observa- 
tion.    Hutchinson  ^  confirms  this  view,  as  do  also  Wood  J  and  At- 

*  "Die  krankhaften  Geschwulste,"  vol.  ii,  p.  4Y1. 

f  "Deutsches  Arcliiv  f.  klin.  Med.,"  Bd.  xxviii,  1880,  p.  94. 
X  "Virchow  und  Hirsch  Jaliresb.,"  xi,  p.  539. 

*  Tolkmann's  "Saniml.  klin.  Yortrii-.,"  1879,  No.  173,  p.  10. 
II  "  Maladies  des  Reins,"  t.  ii,  pp.  489,  493,  498. 

^  "  Vitljahresschrif t.  f.  Derm.  u.  Syph.,"  II,  i,  p.  3.5. 

0  "Lancet,"  i,  1876,  p.  204.  X  "Therapeutics,"  p.  379. 


SYnriLITIC   KIDNEY.  355 

kinson.*  Symptoms  may  be  entirely  absent,  or  there  may  be  only 
lack  of  appetite,  with  sense  of  weakness  and  morning  nausea,  or  there 
may  be  any  and  all  the  symptoms  usually  encountered  in  Bright's 
disease, 

The  pathological  appearances  of  syphilitic  kidney,  besides  amyloid 
defeneration,  which  may  be  found,  perhaps  due  to  the  disease,  are 
those  of  interstitial  chronic  inflammation  (usually  circumscribed), 
local  cirrhosis  (rarely  general),  thickening  of  the  parenchyma  and  cap- 
sule, perhaps  local  fatty  degeneration,  with  atrophy,  the  tough  adhe- 
rent capsule  being  depressed  in  deep  seams,  the  kidney  stroma  com- 
pressed, atrophied,  and  degenerated  between  portions  of  contracted 
connective  tissue.  These  appearances  may  be  found  alone  or  combined 
with  one  or  more  yellow  gummy  nodules,  of  varying  size,  solid,  or 
more  or  less  softened.  Such  nodules  are  usually  connected  to  white 
bands  of  hypertrophied  connective  tissue,  running  through  the  kidney. 
The  gummy  nodule  is  pathognomonic  ;  the  chronic  interstitial  nephri- 
tis is  distinguished  from  the  usual  form  by  being  generally  confined  to 
circumscribed  portions  of  the  gland.  Gummata  are  usually  found 
near  the  surface  of  the  cortex,  and  when  the  kidney  contains  gummata 
the  same  are  generally  found  in  the  liver. 

Greenfield  and  Wagner  have  found  the  walls  of  the  arteries,  in  the 
kidneys  affected  with  syphilitic  disease,  thickened,  with  the  lumen 
nearly  obliterated. 

Trmtmmit  is  mercurial  in  early  syphilis,  mixed  in  late  syphilis,  the 
iodides  being  freely  used,  sometimes  pushed  to  excess ;  but  the  fact 
should  be  constantly  borne  in  mind  that  iodides  alone  may  cause  albu- 
minuria, a  knowledge  of  the  fact  suggesting  the  remedy. 


CHAPTER  XXI. 

DISEASES  OF  TEE  SCROTUM. 


Anatomy.— Injuries.— OSdema.— Emphysema.— Eczema.— Intertrigo.— Pityriasi?.— Eczema  Margina- 
turn. — Pruritus  Genitalium. — Pediculi  Pubis. — Plilegmonous  Erysipelas. — Elephantiasis.— Tumors 
and  Cancer  of  Scrotum. ^Epithelioma. 

The  scrotum  is  a  pouch  formed  of  skin,  muscular  and  connective 
tissue.  Its  function  is  to  contain  and  support  the  testicles.  It  is 
developed  from  two  lateral  halves  which  unite  centrally  in  the  raphe 
(paTTTO),  /  sew),  a  raised  line  continuous  with  the  raphe  of  the  penis 
and  that  of  the  perinseum.  The  lateral  halves  sometimes  remain 
separated  and  resemble  labia  majora,  giving  rise  to  an  appearance  sug- 
gestive of  hermaphrodism.    The  healthy  scrotum  in  the  young  man  is 

*  "American  Journal  of  the  Medical  Sciences,"  July,  1S81,  p.  17  et  seq. 


356  DISEASES  OF  THE  SCROTUM. 

thrown  into  raga3  at  right  angles  to  the  raphe  on  either  side  by  the 
contractions  of  the  dartos. 

The  integument  of  tlie  scrotum  is  delicate  in  structure,  covered  with 
a  few  hairs,  and  a])t  to  become  pigmented  at  puberty.  The  sebaceous 
glands  are  very  large. 

The  dartos  is  a  layer  of  unstriped  muscle.  It  lies  beneath  and 
tirmly  attached  to  the  integument,  and  is  reflected  on  either  side  inward 
from  the  raphe,  to  form  the  septum  scroti.  Each  testicle  has  thus  a 
dartos  of  its  own.  On  exposing  the  scrotum  to  the  air,  the  vermicular 
contractions  of  this  muscle  can  be  readily  seen.  They  occur  under  the 
influence  of  cold  or  fright,  and  during  the  venereal  orgasm.  In  youth, 
especially  in  winter,  the  dartos  is  habitually  contracted  and  holds  the 
testicles  well  up  under  the  pubes.  The  ancient  sculptors  did  not  fail  to 
notice  that  contraction  of  the  scrotum  was  a  mark  of  general  as  well  as 
of  sexual  vigor.  In  the  aged  and  inflrm,  on  the  other  hand,  especially 
during  summer,  the  muscle  relaxes,  allowing  the  testicles  to  hang  low, 
supported  mainly  by  the  cord. 

The  connective  tissue  of  the  scrotum  is  peculiarly  loose,  and  con- 
tains no  appreciable  amount  of  fat.  The  septum  scroti  is  pervious  to 
fluids,  so  that  serum  or  infiltrated  urine  can  find  its  way  readily  from 
one  side  to  the  other.  The  lymphatics  of  the  scrotum  are  large  and 
numerous,  and  lead  to  the  inguinal  glands.  The  scrotum  develops 
independently  of  the  testicles,  but,  if  the  latter  fail  to  descend,  it  is 
always  rudimentary. 

INJURIES    OF    THE    SCROTUM. 

In  contusions,  extensive  ecchymosis  is  liable  to  occur,  on  account  of 
the  laxity  of  the  connective  tissue.  This  should  not  be  incised.  The 
parts  should  be  supported  and  covered  with  cool  lead-water,  to  which 
a  little  spirit  has  been  added,  or  laudanum,  if  there  is  pain.  Absorp- 
tion may  be  pretty  confidently  expected. 

In  wounds  of  the  scrotum  there  is  usually  a  great  deal  of  bleeding. 
In  uniting  such  wouuds,  many  sutures  are  required,  to  overcome  the 
tendency  of  the  dartos  to  pull  the  edges  apart.  Abscess  of  the  scrotum 
after  injury  requires  no  comment.     An  early  opening  is  advisable. 

CUTANEOUS    AFFECTIONS    OF    TEE    SCROTUM. 

Nearly  all  of  the  numerous  diseases,  syphilitic  or  otherwise,  of  the 
general  integument,  may  occur  also  upon  the  scrotum.  Certain  of 
them  are  modified  by  their  position,  and  require  a  passing  notice. 

Extensive  (edema  is  liable  to  complicate  any  inflammatory  affection 
of  the  scrotum,  on  account  of  the  laxity  of  its  tissue  and  its  dependent 
position.  Scrotal  oedema  may  also  be  due  to  any  obstruction  to  the 
return  of  its  blood,  as  occasionally  to  the  hard  inflammatory  induration 


EMPHYSEMA— ECZEMA   MARGINATUM.  357 

around  inflamed  lymphatic  glands  in  the  groin,  or  it  may  come  on  in 
connection  with  general  prostration  and  anasarca. 

Where  oedema  is  excessive,  and  the  tension  is  so  great  that  injury  t.o 
the  skin  seems  imminent  from  pressure,  a  few  punctures  may  he  made 
on  either  side  of  the  raphe,  at  the  most  depending  point  of  the  scrotum. 
These  punctures,  however,  should  be  practiced  with  caution,  as  there 
is  danger  of  their  being  followed  by  gangrenous  erysipelas. 

Em'pliysema  of  the  scrotum  is  occasionally  met  with.  It  is  easily 
distinguished  by  the  crackling  under  the  lingers,  and  resonance  on 
percussion.  It  occurs  with  general  subcutaneous  emphysema,  and  with 
scrotal  gangrene. 

Eczema. — Eczema  attacking  the  scrotum,  perinaeum,  and  thighs 
around  the  root  of  the  scrotum,  is  apt  to  be  excessively  obstinate,  and 
prone  to  relapse.     (For  treatment,  see  text-books  on  dermatology.) 

Intertrigo  occurs  in  children,  and  often  in  fat  men  of  rheumatic 
habit  who  perspire  a  good  deal.  This  affection  is  apt  to  be  trouble- 
some. Much  can  be  done  to  prevent  it,  by  scrupulous  cleanliness,  and 
the  use  of  a  suspensory  bandage,  to  keep  the  cutaneous  surfaces  apart. 
To  overcome  the  hyperasmia  when  it  exists,  rest,  cleanliness,  and  ex- 
posure of  the  parts  to  the  air  are  speedily  effective  in  mild  cases.  If 
the  surface  is  moist  and  excoriated,  it  should  be  dusted  with  equal 
parts  of  finely  powdered  oxide  of  zinc,  camphor,  and  starch,  or  it  may 
be  dressed  with  the  oxide-of-zinc  ointment  or  with  a  solution  of  sul- 
phate of  zinc.  A  strip  of  old  thin  linen  should  be  used  to  sling  up  the 
scrotum  and  keep  the  cutaneous  surfaces  apart.  Later,  when  the 
parts  are  dry,  tincture  of  iodine,  locally,  will  hasten  the  cure.  Avoid- 
ance of  stimulating  food  and  drink,  to  render  the  secretions  less  irri- 
tating, is  advisable. 

Pityriasis. — In  men  with  a  delicate  skin,  especially  in  summer, 
there  is  often  a  slightly  brown  discoloration  of  the  thigh  and  of  the 
scrotum,  where  the  two  surfaces  lie  habitually  in  contact,  caused  by 
a  vegetable  parasite  in  the  upper  layers  of  the  epidermis.  It  is,  in 
fact,  a  pityriasis  versicolor,  and  sometimes  gives  rise  to  a  mild  local 
erythema  and  considerable  itching.  A  few  applications  of  the  com- 
pound tincture  of  iodine  diluted  to  half  strength,  and  painted  on  after 
the  affected  skin  has  been  washed  with  soap  and  dried  (to  remove  the 
fat  from  the  scales  and  spores),  will  cure  the  discoloration  and  the 
itching.     Sulphurous  acid  does  well. 

Eczema  Marginatum. — This  is  another  parasitic  disease,  affecting 
the  scrotum,  thighs,  mons  veneris,  and  buttocks.  It  is  not  an  eczema, 
but  a  herpes  tonsurans  vesiculosus — a  combination  of  herpes  tonsurans 
and  intertrigo,  as  proved  by  Pick,*  in  a  written  discussion  with  Hebra. 
The  eruption  commences  in  one  or  more  small,  round  patches,  red, 

*  "  Zur  Verstandigung  iiber  das  sogenannte  Ekzema  Marginatum,"  "  Archiv  f .  Derm 
und  Syph.,"  1,  iii,  p.  443. 


35S  DISEASES  OF  THE  SCROTUM. 

elevated,  and  itchy,  just  where  the  scrotum  lies  habitually  in  contact 
with  the  thigh.  It  spreads  circumfcrentially,  healing  in  the  center. 
The  border  of  the  eruption  is  sharply  defined,  and  forms  the  distinct- 
ive feature  of  the  disease.  It  is  composed  of  papules,  vesicles,  excoria- 
tions, and  crusts.  The  parts  within  this  festooned  border  over  which 
the  disease  has  passed  are  left  of  a  brown  color.  Often,  little  hea]is 
of  dried-up  scales  lie  here  and  there  upon  this  surface.  Patches  of 
eruption  break  out  in  the  neighborhood  or  within  the  border,  and 
behave  exactly  like  the  patches  first  constituting  the  disease.  The 
affection  is  slow  in  getting  well,  and  tends  strongly  to  relapse.  Fric- 
tion and  moisture  of  the  parts,  together  with  the  parasite,  are  neces- 
sary for  its  production.  Among  the  scales  scrajied  from  the  margin, 
the  microscope  may  detect  the  moniliform  filaments  and  spores  of  the 
tricophyton  of  Malmster,  the  parasite  of  ordinary  ringworm.  In  cer- 
tain stages  of  the  disease,  the  parasite  is  difficult  to  find. 

Treatment. — Dilute  lead-water  or  oxide-of-zinc  ointment  may  be 
used  locally  at  first  if  there  be  much  inflammation  of  the  skin,  to  be 
followed  by  parasiticide  lotions,  or  the  latter  may  be  commenced  with 
at  once.  The  best  of  these  is  a  mild  solution  of  corrosive  sublimate  in 
water,  gr.  j-jss  to  the  3  j,  which  should  be  kept  constantly  applied. 
Sulphurous  acid,  pure,  is  an  excellent  parasiticide  ;  tincture  of  iodine 
may  be  used,  or  an  ointment  of  turpeth  mineral  (hydrarg.  sulph.  flav.) 
gr.  x-xx  to  the  3  j.  Treatment  should  be  kept  up  for  some  time 
after  apparent  cure,  as  relapses  are  the  rule,  and  can  only  be  averted 
in  this  way. 

Pruritus  Genitalium. — This,  like  other  purely  pruriginous  skin- 
affections  without  eruption,  is  excessively  obstinate.  Rheumatic  and 
gouty  subjects  most  often  are  the  sufferers,  and  with  such,  any  dietetic 
or  hygienic  errors  seem  liable  to  induce  or  aggravate  the  disorder. 
After  the  exclusion  of  animal  or  vegetable  parasites  from  the  role  of 
causality,  the  treatment  consists  in  hygienic  and  dietetic  precautions, 
with  the  internal  exhibition  of  alkalies,  and,  if  need  be,  tonics.  Turk- 
ish and  Eussian  baths  are  often  very  serviceable. 

The  following  are  among  the  most  generally  useful  local  measures, 
what  is  suitable  for  one  case  often  having  no  effect  upon  another.  Hy- 
giene and  change  of  air  are  sometimes  the  only  really  curative  agents. 

Hot  water,  tar,  pure  or  in  combination,  yellow  wash,  chloral, 
camphor ;  or, 

V/,     Cliloroform,  3  j. 

Adipis,  I  j. 

M.     Keep  corked  in  a  vride-mouthcd  bottle. 


Or, 


5     Acid,  hydrocyanic,  dil.,  3  ss-  3  iv. 

Glycerini,  3  j- 

Aqute,  q.  s.  ad  §  j. 

M.  Ft.  lotio. 


PEDICULI  PUBIS— PHLEGMONOUS  ERYSIPELAS.  350 

Finally,  local  electricity,  either  tlie  induced  or  the  continued  current, 
has  moderate  curative  power  over  some  cases. 

Pediculi  Pubis. — These  parasites  may  be  found  upon  the  scrotum, 
as  they  may,  in  fact,  upon  any  part  of  the  body  from  which  the  hairs 
of  puberty  grow.     They  exist  in  greatest  abundance,  however,  about 
the  genitals,  and  particularly  on  the  mons 
veneris.     They  are  plainly  visible  to  the 
naked  eye,  as  are  their  eggs  attached  to 
the  hairs  (Fig.  105,  a).     They  may  be  de- 
stroyed by  sprinkling  the  parts  with  calo- 
mel, or  by  applying  a  lotion  of  gr.  j-iij 
corrosive   sublimate   to  |  j   of    Cologne- 
water,  or  a  wash  made  of  equal  parts  of 
tincture  delphinii  and  water,  or  by  the 
free  local  use  of  kerosene-oil.    When  they  p^^  ^q- 

infest  the  whole  body,  some  few  usually 

escape  the  ordinary  application  of  lotions,  and  these  soon  breed  a  new 
crop.  Care  and  patience,  however,  will  always  finally  dislodge  them. 
No  treatment  is  better  than  the  old-fashioned  blue  mercurial  oint- 
ment, half  an  ounce  of  which  may  be  rubbed  into  the  hairy  parts 
about  the  pubis  and  perinseum  and  somewhat  down  the  thighs,  the 
patient  going  to  bed  in  drawers  and  sleeping  in  the  ointment  all  night. 
Two  such  applications,  at  a  few  days'  mterval,  generally  destroy  the 
colony.  The  treatment  is  a  very  dirty  one,  and  much  soap  and  hot 
water  form  essential  parts  of  it.  Moursou,  a  French  naval  surgeon, 
first  pointed  out  the  relation  between  certain  blue  spots  on  the  skin 
and  pediculi  pubis,*  and  Douguet  confirmed  the  relationship  by  in- 
serting a  bruised  pediculus  under  the  skin  and  producing  a  spot. 
Mallet  proved  that  the  coloring  matter  resides  in  the  salivary  glands 
of  the  pediculus.  In  the  early  spring  the  spots  are  more  abundant 
than  in  other  months. 

TJeikaet  Infiltration"  has  been  already  described. 

Phlegmonous  Erysipelas. — Upon  the  scrotum  this  is  an  exceed- 
ingly dangerous  disease.  It  is  most  frequently  observed  in  the  aged 
or  debilitated.  Injuries  and  operations  may  also  be  occasionally  at- 
tended by  it.  The  so-called  metastatic  inflammations  occurring  in 
typhus,  variola,  scarlet  fever,  mumps,  etc.,  are  in  reality  phlegmonous 
erysipelas,  described  by  some  English  authors  as  acute  oedema. 

Symptoms. — A  sharp  chill  announces  the  disease.  The  scrotum 
becomes  at  once  the  seat  of  increased  heat  and  redness,  with  pain,  and 
rapidly  enlarges.  Blood  escapes  into  the  subcutaneous  connective  tis- 
sue, so  that  the  whole  scrotum  may  be  black  and  shining,  or  its  color 
may  be  mottled.  The  scrotum  may  reach  the  size  of  a  child's  head, 
the  integument  is  put  upon  the  stretch,  the  epidermis  may  crack  or 

*  "Lancet"  (editorial),  September  16,  1SS2,  p.  454. 


360  DISEASES  OF  THE  SCROTUM. 

may  be  raised  into  vesicles  or  bii]la\  The  general  tendency  of  the 
disease  is  always  toward  gangrene.  Pain  is  not  very  great,  but  the 
prostration  is  excessive.  The  pulse  runs  up  to  120-100,  is  small, 
feeble,  and  irregular.  The  appetite  fails,  the  tongue  gets  brown  and 
dry,  the  patient  breathes  hurriedly,  is  depressed  and  overcome.  The 
skin  is  hot  and  dry  at  first,  but  becomes  subsc(piently  moist  from  de- 
jiression. 

The  diagnosis  is  between  infiltration  of  urine  and  lifematocele. 
From  the  former  it  may  be  distinguished  by  the  greater  severity  of 
the  attack,  the  rapid  change  of  color  of  the  parts,  the  fact  that  one 
side  of  the  scrotum  is  more  seriously  involved  than  the  other  in 
phlegmonous  erysipelas,  and  that  the  oedema  does  not  so  certainly  ex- 
tend to  the  penis  and  abdomen.  The  patient  is  more  depressed,  and 
no  pre-existing  cause  for  infiltration  is  present.  In  true  ha?matocele 
one  side  only  of  the  scrotum  is  enlarged,  and  there  is  not  much  thick- 
ening of  the  skin.  The  swelling  may  be  often  made  out  as  involving 
the  testicle.  The  general  symptoms  in  ha?matocele  are  not  formidable. 
The  dangers  in  phlegmonous  erysipelas  of  the  scrotum  are  twofold  : 
the  life  of  the  jiatient  is  in  danger  ;  the  integrity  of  the  scrotum  is  at 
stake ;  any  portion  or  the  whole  of  it  may  slough,  leaving  the  testi- 
cles uncovered. 

Treatment. — The  treatment  should  be  energetic  and  supportive. 
Repeated  small  doses  of  brandy,  whisky,  or  -wine,  must  be  given,  with 
milk,  cream,  and  beef-tea.  The  quantity  of  stimulant  varies  in  every 
case.  Eight  or  ten  ounces  of  brandy  or  whisky  in  twenty-four  hours, 
in  small  portions  at  a  time,  is  a  fair  average  quantity.  A  good  effect 
of  the  stimulant  will  be  noticed  in  the  pulse,  which  will  decrease  in 
frequency  and  become  more  strong  and  regular.  The  tongue  will  get 
moist,  and  the  patient  rally  from  his  depression. 

The  local  treatment  is  equally  important.  Hope  of  aborting  the 
disease  need  not  be  entertained.  One  long,  free  incision  parallel  to 
tlie  rajohe,  on  either  side,  should  be  made  well  down  into  the  sub- 
cutaneous tissue  of  the  oedematous  discolored  mass.  Persulphate  of 
iron  may  be  used,  if  necessary,  to  check  bleeding,  and  water-dressings, 
with  one  per  cent  carbolic  acid,  applied.  If  gangrene  has  already 
commenced,  and  sloughs  begun  to  separate,  or  if  the  latter  form  in 
spite  of  the  incision,  they  should  be  detached  and  removed  as  soon  as 
possible.  The  testicles  hang  out  uninjured  in  these  cases,  suspended 
by  the  cord,  and  if  left  to  themselves  and  kept  moist,  or,  perhaps  bet- 
ter, mildly  stimulated,  granulations  will  sprout  out  upon  them,  and  a 
cicatrix  will  form,  binding  them  up  under  the  pubis  in  a  manner  not 
unsightly  nor  inconvenient.  The  patient  is  always  agreeably  disap- 
pointed in  the  final  result.  If  the  process  of  repair  does  not  form  a 
good  scrotum,  recourse  may  be  had  to  oscheolasty  {ocrxeov,  scrotum ; 
irXdora-w,  to  form),  as  performed  by  Delpech,  Dieffenbach,  Diirger,  and 


ELEPHANTIASIS— CANCER— EPITHELIOMA.  301 

others,  by  transplanting  from  neighboring  parts  flaps  of  skin  large 
enough  to  cover  in  the  testicles. 

Elephantiasis  Sceoti. — This  disease,  not  uncommon  in  some 
portions  of  the  globe,  is  rare  in  the  United  States.  Hypertrophic 
overgrowth  may  attack  the  scrotum  or  penis  alone,  but  usually  botJi 
are  involved,  the  scrotum  to  the  greater  extent.  The  scrotum  may 
enlarge  until  it  touches  the  ground.  It  has  been  known  to  reach  the 
weight  of  one  hundred  and  sixty-five  pounds  !  A  scrotum  of  this 
weight  was  removed  by  Wilkes.*  Tlie  only  remedy  for  the  disease  is 
the  knife.  Curling  advises  a  disregard  of  the  penis  and  testicles  in 
operating,  if  the  tumor  be  very  large.  Patients  are  apt  to  die  on  the 
table,  from  hemorrhage,  which  is  always  excessive.  If  the  mass  is 
not  excessively  large,  the  penis,  testicles,  and  cords  may  be  dissected 
out,  enough  of  the  healthiest  tissue  being  left  to  cover  them.  Many 
cases  of  successful  operation  are  recorded,  among  others,  one  by  The- 
baud,  of  New  York,  the  mass  weighing,  when  removed,  sixty-three 
pounds. 

Lymph  Scrotum  (pachydermia  lymphangiectatica — Rindlleisch)  is 
analogous  to  and  suggestive  of  elephantiasis  scroti.  The  names  of 
Carter,  Manson,  Eoberts,  and  Wiedel  are  best  known  in  connection 
with  it.  Numerous  vesicles  and  tubercles,  discharging  lymph  when 
punctured,  are  found  upon  an  hypertrophied  scrotum,  and  the  malady 
tends  to  prolong  itself  indefi.nitely.  The  disease  is  doubtless  due  to 
filaria  Bancroftii.  Busey  f  considers  the  subject.  In  one  of  Carter's  J 
cases,  chylous  urine  alternated  more  or  less  regularly  with  a  flow  of 
lymph  from  the  tubercles  on  the  scrotum.  A  punctured  tubercle 
would  sometimes  yield  a  pound  of  chylous  fluid  a  day. 

Cystic,  fatty,  and  fibrous  tumors  of  the  scrotum  are  found  occa- 
sionally. Small  steatomatous  cysts  are  common.  They  may  reach  a 
large  size. 

Can^cer  of  the  Scrotum,  in  this  country,  is  a  rare  disease.  When 
it  occurs,  it  is  almost  invariably  epithelial.  Scirrhous  and  medullary 
cancer,  recurrent  fibroid,  and  melanotic  sarcoma,  are  encountered  at 
long  intervals,  but  not  as  differing  in  any  way  from  the  same  growths 
elsewhere. 

Epithelioma  of  the  Scrotum  has  been  denominated  chimney- 
sweeps' cancer,  since  it  is  somewhat  common  in  England  upon  chim- 
ney-sweepers. Soot  seems  to  be  the  exciting  cause  in  England, 
although  in  other  countries  those  whose  occupation  brings  them  into 
contact  with  this  substance  do  not  seem  to  suffer.  On  the  contrary, 
our  countryman,  Warren,*  states  that  he  has  seen  it  a  few  times  in 

*  Titley,  "Diseases  of  the  Genitals,"  p.  317. 

f  "  Congenital  Occlusion  of  Lymph-channels,"  New  York,  1S7S,  p.  98. 
X  "Med.-Chir.  Trans.,"  1862,  vol.  slv,  p.  189. 

*  "Surgical  Observations  on  Tumors,"  p.  329.  ~ 


362  DISEASES  OF  THE  TESTICLE. 

the  Uuited  States,  but  never  in  chimney-sweepers.  Coalrdust  is  en- 
tirely inoperative. 

The  disease  begins  as  one  or  more  small,  soft  warts,  or  tubercles, 
usually  at  the  lower  fore-part  of  the  scrotum.  These  remain  un- 
changed for  a  time,  but  finally  indurate  slightly,  become  excoriated, 
scab  over,  and  ulcerate,  the  ulcer  extending  backward,  and  destroy- 
ing, with  more  or  less  rapidity,  the  whole  scrotum.  Sometimes  the 
testicles  are  involved,  sometimes  they  escape.  The  ulcer  resembles  an 
epithelial,  cancerous  ulceration,  wherever  seen.  It  has  the  same 
hardened,  irregular,  purplish,  everted,  knotty  borders  ;  the  same  hard, 
uneven,  unhealthy-looking  base  ;  the  same  ichorous  discharge,  now 
sanguinolent,  now  purulent. 

Death  occurs  by  exhaustion,  or  by  haemorrhage,  if  a  large  vessel 
be  severed  by  the  advancing  ulceration.  The  disease  continues  local 
for  some  time.  It  is  only  tardily  that  the  inguinal  glands  become  in- 
volved. 

Treatment. — Thorough  removal  with  the  knife  offers  the  only 
chance  for  safety.  If  the  inguinal  glands  have  not  become  infected, 
the  operation  is  a  simple  one.  If  either  testicle  should  be  found  in- 
volved, or  even  adherent  to  the  diseased  mass,  it  should  be  removed. 
If  the  glands  in  the  groin  are  greatly  enlarged  and  indurated,  opera- 
tion is  unadvisable.  If  they  are  only  slightly  enlarged,  they  may  be 
left ;  but,  if  they  are  at  all  indurated,  they  too  must  be  removed. 
The  earlier  the  operation  is  undertaken  the  less  the  chance  of  relapse, 
which  is  always  to  be  feared.  A  second  and  third  operation  may  be 
advisable,  if  the  patient's  general  condition  be  not  seriously  impaired. 

(For  mucous  patches  of  the  scrotum,  see  Syphilis.) 


CHAPTEK  XXII. 

DISEASES   OF  THE  TESTICLE. 

Anatomy.— Anomalies.— Cryptorchidism.— Lnxation.—ITypertrophy.— Atrophy.— Injuries.— 
ITiEmatocele.— Ha;matocele  of  tlie  Cord.— Free  Bodies  in  the  Tunica  Vaginalis. 

The  testicles,  suspended  each  by  its  spermatic  cord,  lie  loosely  in 
the  scrotum,  surrounded  by  connective  tissue.  The  left  is  usually 
slightly  larger  than  the  right  and  hangs  lower,  evidently  for  the  pur- 
pose of  allowing  these  important  organs  the  more  readily  to  elude 
violence.  It  has  been  observed,  in  transposition  of  the  viscera  and 
blood-vessels,  that  the  right  testicle  hangs  the  lower.  The  mean  di- 
mensions of  the  testicle,  according  to  Curling,  are  one  and  three 
fourths  inch  long,  one  and  a  fourth  inch  antero-posteriorly,  and  one 


EPIDIDYMIS.  363 

inch  laterally.  The  average  weight  in  the  adult  is  about  six  drachms. 
The  dimensions,  weight,  and  consistence  vary  considerably,  according 
as  the  organ  is  in  action  or  not.  During  venereal  excitement  it  is 
turgesccnt,  firm,  and  elastic  ;  otherwise  soft  and  yielding.  Two  of 
the  envelopes  of  the  cord  also  cover  the  testicle,  the  cromaster  mu.scle 
and  the  tunica  vaginalis  communis,  while  the  remains  of  the  guber- 
naculum  testis  attach  it  to  the  bottom  of  the  scrotum. 

The  proper  coverings  of  the  testicle  are  two — the  tunica  vaginalis 
testis  and  the  tunica  albuginea.  The  former  is  a  shut  serous  sac,  in- 
vesting all  the  secreting  portion  of  the  testicle,  except  where  the  epi- 
didymis is  attached  behind,  and  the  remains  of  the  gubernaculum  be- 
low. It  dips  down  in  the  middle  posteriorly,  between  the  epididymis 
and  the  testicle,  forming  a  cul-de-sac,  at  the  bottom  of  which  the  sac 
on  the  two  sides  comes  into  close  contact,  and  sometimes  there  is  a 
communication  at  this  point.  On  the  outer  side  the  tunica  vaginalis 
covers  and  closely  invests  the  epididymis.  The  reflected  layer  forms 
a  shut  sac,  and  this  extends  up  the  cord  to  a  greater  or  less  extent. 
This  tunica  vaginalis  represents  a  portion  of  the  peritonaeum  which 
was  brought  down  by  the  testicle  in  its  descent  from  the  abdomen. 
Ordinarily,  at  birth,  all  connection  between  its  cavity  and  that  of  the 
peritonaeum  is  closed,  a  white,  fibrous  line  (habenula)  alone  marking 
the  original  continuity  of  membrane.  Sometimes,  however,  the  open- 
ing remains  permanent,  in  which  case  congenital  hernia  is  likely  to 
occur.  The  communication  may  be  a  narrow  canal,  open  only  to  the 
passage  of  fl.uid.  Again,  partial  obliteration  may  exist,  isolated  serous 
sacs  being  left  along  the  cord.  Finally,  as  more  often  happens,  the 
upper  aperture  is  closed,  and  a  considerable  portion  below  remains 
unobliterated,  so  that  the  tunica  vaginalis  extends  for  some  distance 
upward  in  front  of  the  cord.  The  cavity  of  the  tunica  vaginalis  is 
lined  by  pavement  epithelium,  and  normally  contains  only  enough 
fluid  to  lubricate  the  surfaces.  The  function  of  the  sac  is  to  allow 
the  testicle  to  slip  easily  away  when  in  danger  of  being  pinched. 

The  tunica  albuginea  is  the  proper  investing  membrane  of  the  se- 
creting portion  of  the  testicle.  In  its  substance  the  branches  of  the 
spermatic  artery  ramify,  and  break  up  to  be  distributed  to  the  seminal 
tubules  within.  It  is  composed  of  dense,  white,  fibrous  tissue,  is  only 
slightly  extensible  (whence  the  pain  in  orchitis),  and  sends  trabecul^e 
into  the  substance  of  the  testicle  to  break  it  up  into  compartments 
(about  four  hundred  for  each  testicle)  for  the  lodgment  of  the  ulti- 
mate tubuli  seminiferi.  It  forms  the  rete  testis  (corpus  Highmori) 
above  and  behind,  where  blood-vessels  and  absorbents  pass  to  and  from 
the  testicle,  and  where  the  straight  tubes  come  out  to  form  the  coni 
vasculosi — together,  the  head  of  the  epididymis. 

The  glandular  substance  of  the  testicle  consists  of  innumerable 
little  tubes  (tubuli  seminiferi)  closely  packed  in  conical  segments  be- 


364  DISEASES   or   THE   TESTICLE. 

tween  the  fine,  fibrous  septa  thrown  out  by  tlic  tunicu  albuginoa. 
The  number  of  these  cones  is  coni})uted  to  bo  from  2b0  to  about  5C0, 
and  their  combined  length  from  1,UU0  to  5,500  feet.  The  diameter 
of  tlie  tubules  has  been  yariously  estimated  at  from  ^  of  a  line  (Miil- 
ler)  to  -^^  of  a  line  (Lauth).  Their  mean  length  is  estimated  by 
Lauth  at  25  inches. 

The  tubes  are  all  of  the  same  size  throughout,  and  anastomose  fre- 
quently with  their  fellows  of  the  same  cone,  and  with  those  of  neigh- 
boring cones.  They  are  lined  with  mucous  membrane  furnished  with 
polygonal  cells,  containing  spherical  nuclei.  These  cells  are  the  act- 
ive agents  in  forming  the  spermatozoa,  the  ciliated  cells  (so-called 
animalcula?)  always  found  in  health  after  puberty,  free  in  the  tubes  in 
greater  or  less  number,  according  to  circumstances. 

The  ej)i(Iidiji)u\^  [iirc,  upon;  ScSv/aos,  testicle)  caps  the  testicle  proper, 
and  skirts  its  posterior  border.  It  is  large  and  spread  out  above,  be- 
ing composed  of  the  coni  yasculosi  or  convoluted  vasa  efferentia. 
This  portion  is  known  as  the  globus  major,  or  head  of  the  epididymis. 
The  coni  vasculosi  finally  all  empty  into  one  canal — the  canal  of  the 
epididymis,  which  forms  by  its  convolutions  the  central  pari  or  body 
of  the  epididymis.  This  body  is  separated  from  the  testicle  proper  by 
the  cid-de-sac  of  the  tunica  vaginalis  already  alluded  to.  Below,  the 
canal  of  the  epididymis  exhibits  further  convolutions.  At  this  point 
it  is  known  as  the  globus  minor,  or  the  tail  of  the  epididymis.  Con- 
nective tissue  unites  it  to  the  testicle  at  this  point,  and  from  here  on 
the  canal  becomes  more  dense,  and  is  known  as  the  vas  deferens. 

The  little  supernumerary  diverticulum  (or  there  may  be  several), 
known  as  the  vasculum  aberrans  of  Haller,  when  present,  usually 
empties  into  the  canal  of  the  epididymis  at  this  point.  The  canal  of 
the  epididymis  is  furnished  with  ciliated  epithelium,  whose  cilia  sweep 
its  contents  along  toward  the  vas  deferens. 

The  two  constituent  parts  of  the  testicle,  which  have  been  briefly 
described  above,  are  developed  separately  in  the  foetus.  Each  re- 
ceives its  blood  in  the  main  from  a  separate  artery,  although  these 
arteries  anastomose  pretty  freely  at  their  extremities.  This  peculiar- 
ity of  Tascular  supply  may  account  for  the  fact  that  one  portion  of 
the  organ  is  often  diseased,  the  other  part  remaining  sound.  The  epi- 
didymis is  formed  from  the  lower  part  of  the  Wolffian  body,  and  its 
duct  is  a  continuation  of  the  Woltlian  duct  to  the  lower  and  back 
part  of  the  bladder.  The  deferential  artefy,  a  branch  of  the  hypo- 
gastric, supplies  it.  The  secreting  portion  of  the  testicle,  on  the 
other  hand,  is  formed  from  fetal  tissue  lying  in  front  of,  but  seem- 
ingly independent  of,  the  Wolffian  body,  and  its  artery,  the  spermatic, 
comes  from  the  aorta  just  below  the  renal  artery  (Kolliker).* 

*  "Entwickelungs-Geschichtc  des  Menschen  und  der  boheren  Thiere." 


CRYPTORCHIDISM.  305 

ANOMALIES    OF    THE    TESTIS. 

Instances  of  supemumcrury  testicles  have  been  reported,  but  in  all 
tlie  cases  where  dissection  has  been  resorted  to,  to  clear  up  the  doubt, 
the  extra  organ  has  proved  to  bo  some  cystic,  fatty,  fibrous,  or  otlier 
tumor,  so  that  it  is  doubtful  if  the  anomaly  exists  at  all.  Even  in  the 
observed  cases  of  double  penis  there  was  no  abnormality  of  the  testi- 
cles. The  opposite  condition,  however — absence  of  the  testicle — does 
exist  (Paget).*  One  or  both  testicles  may  be  absent ;  the  vas  deferens 
and  seminal  vesicle  in  these  cases  being  sometimes  fully  developed,  and 
ti-aceable  into  the  inguinal  canal,  or  even  to  the  bottom  of  the  scrotum 
(Curling). 

CHYPTORCHIDISM-MONORCHIDISM.t 

A  CRYPTORCHiD  (KpuVretv,  to  concectl ;  opxi%  testicle)  is  an  individ- 
ual whose  scrotum  contains  no  testicles. 

A  MONORCHID  (/xoVo?,  oloQie  ;  opxi.^,  testicle)  has  only  one  testicle  in 
the  scrotum. 

When  a  testicle  is  absent  from  the  scrotum,  the  presumption  is  that 
it  has  been  arrested  somewhere  in  its  descent.  The  testicle  is  formed 
high  up  in  the  abdominal  cavity,  behind  the  peritonaeum,  in  about 
the  position  occupied  by  the  lower  end  of  the  kidney  at  birth.  Dur- 
ing fetal  life,  guided  by  the  gubernaculum  testis,  it  descends,  carry- 
ing with  it  a  portion  of  peritongeum,  which  is  to  become  the  tunica 
vaginalis.  It  passes  through  the  inguinal  canal,  and  by  the  end  of 
the  ninth  month  is  usually  in  the  scrotum.  It  may,  however,  be  ar- 
rested at  any  point  in  its  descent,  or  may  follow  an  abnormal  direc- 
tion, finding  its  way  into  the  thigh  through  the  femoral  ring,  or  even 
into  the  perinseum,  where  it  may  become  inflamed,  and  has  been  mis- 
taken for  an  abscess.  One  very  common  point  of  detention  is  in  the 
inguinal  canal.  In  all  of  these  situations  it  can  be  felt,  and  should  be 
searched  for  in  case  the  scrotum  is  empty.  In  about  one  case  in  five 
(or  ten — Wrisberg)  the  testicle  is  not  in  the  scrotum  at  birth.  It  de- 
scends, usually,  during  the  first  week,  but  is  often  retained  for  mouths, 
sometimes  longer,  and  not  very  infrequently  until  puberty,  or  even 
later ;  it  has  been  known  to  descend  as  late  as  thirty  years  after  birth. 

*  "Medical  Gazette,"  vol.  xxix,  p.  817. 

f  The  literature  on  this  subject  is  rich.  The  following  papers  may  be  consulted  with 
profit : 

FoUin,  "Mem.  sur  les  Anomalies  de  Position  du  Testicule,"  "Archiv.  de  Med.,"  18.51. 

Le  Comte,  "These  sur  les  Ectopics  congenitales  des  Testicules,"  1851. 

Roubaud,  "  Traite  de  I'lmpuissance,"  Paris,  1872,  p.  607. 

Godard,  "  Etudes  sur  1' Absence  congenitale  du  Testicule,"  "  Mem.  de  la  Societe  de 
Biologic,"  1856-'o9. 

Godard,  "6tude  sur  la  Monorchidie  et  la  Cryptorchidie  chez  I'Homme,"  Paris,  1857. 

Godard,  "Etudes  sur  1' Absence  congenitale  du  Testicule,"  1S58. 


3GG  DISEASES  OF  THE  TESTICLE. 

When  it  descends  after  birth  there  is  great  probability  that  a  portion 
of  intestine  will  follow  it,  constituting  congenital  hernia.  It  is  esti- 
mated that  in  about  one  case  in  a  thousand  the  testicle  is  permanently 
retained  in  the  abdomen,  or  inguinal  canal.  The  right  testicle  is  a 
little  more  liable  to  this  accident  than  the  left  (Petreqnin  Quctclet). 

"When  the  testicle  is  retained  in  an  abnormal  position,  it  is  almost 
universally  found  undeveloiicd,  or  in  a  state  of  fatty  or  fibrous  degen- 
eration. Under  these  circumstances  no  spermatozoa  arc  discovered  in 
it,  or  in  the  seminal  vesicle  of  the  atlectcd  side.  Excci)tionally,  how- 
ever, it  has  been  found  of  full  size.  When  one  testicle  only  is  re- 
tained, the  other  undergoes  conservative  hypertrophy,  and  the  deform- 
ity is  a  matter  of  no  consequence,  as  one  large,  healthy  testicle  is  all- 
sufficient.  But,  where  both  testicles  are  retained,  it  may  become  a 
very  nice  matter  in  a  medico-legal  sense,  or  in  regard  to  prospective 
matrimony,  to  decide  whether  the  cryptorchid  is  sterile  or  not.  Ac- 
cording to  Godard,  the  cryptorchid  is  necessarily  sterile,  yet  he  may 
be,  and  usually  is,  thoroughly  potent,  and  possessed  of  the  full  amount 
of  sexual  desire.  An  opinion  of  his  ability  to  beget  children  can  only 
be  founded  upon  microscopic  examination  of  the  spermatic  fluid. 
The  secretion  may  be  natural  in  consistence,  quantity,  and  odor  (it  is 
liable  to  be  brownish),  but,  if  it  does  not  contain  spermatozoa,  im- 
pregnation can  not  be  effected.  The  least  offensive  way  of  obtaining 
a  specimen  for  examination  is  to  request  the  patient,  immediately 
after  sexual  congress,  to  cause  the  woman  with  whom  he  has  cohabited 
to  urinate,  and  then  to  bring  the  urine  for  examination.  When  al- 
lowed to  settle  for  a  short  time,  spermatozoa  can  always  be  recovered, 
Avith  a  pipette,  from  such  a  specimen,  provided  the  seminal  fluid  con- 
tained any.  Several  cases  are  recorded  where  cryptorchids  have  mar- 
ried, whose  wives  have  had  children,  but  doubt  has  always  been  raised 
as  to  the  paternity  of  the  offspring.  Authors  are  not  of  accord  as  to 
the  sterility  or  virility  of  cryptorchids.  The  majority  take  the  former 
ground,  but,  as  these  individuals  are  apparently  never  impotent,  the 
test  of  their  sterility  can  be  easily  applied,  if  desirable. 

The  retained  testicle  is  apt  to  become  diseased.  When  retained  in 
the  inguinal  canal,  it  is  often  the  seat  of  severe  pain,  especially  at 
about  the  age  of  puberty,  from  pressure  by  the  tendons  of  the  abdomi- 
nal muscles.  It  may  be  painful  enough  to  impede  motion,  in  which 
case  an  operation  should  be  undertaken  for  its  removal.  A  testicle  in 
this  situation  is  liable  to  become  the  scat  of  malignant  disease,  due 
partly,  according  to  Virchow,  to  the  injuries  inflicted  upon  it  by  the 
contractions  of  the  abdominal  muscles,  and  partly  to  a  predisposition 
from  its  incomplete  development.  A  testicle  in  this  situation,  which 
becomes  inflamed,  as  it  may  in  connection  with  gonorrhoea,  is  not 
able  to  swell,  and  consequently  is  doubly  painful.  Testicles  retained 
in  the  inguinal  canal  may  be  mistaken  for  hernia. 


CRYPTORCHIDISM.  3f;7 

Operations  to  replace  a  testicle  when  found  in  uu  abnormal  posi- 
tion have  been  executed  with  measurable  success.  When  the  organ 
in  early  life,  as  is  often  the  case,  can  be  manipulated  outside  of  tlie 
external  ring,  and  retained  there  by  a  truss  having  a  water  or  a  gly- 
cerine jiad,  if  it  is  so  retained  for  a  long  series  of  months,  it  may 
eventually  become  lodged  outside  the  ring,  and  develop  normally  in 
this  situation  Just  over  the  pubic  bone.  I  have  succeeded  in  this  en- 
deavor several  times.  Truly,  the  testicle  in  this  position  is  exposed 
to  injury  more  than  it  would  have  been  if  left  in  the  inguinal  canal, 
yet  its  integrity  is  preserved,  it  develo^DS  normally,  and  the  ring  may 
be  closed  by  the  pressure  of  the  pad,  and  the  risk  of  hernia  greatly 
lessened.  This  risk  patients  with  a  testicle  retained  in  the  canal 
always  run.  I  have  had  to  operate  for  strangulated  hernia  under 
these  circumstances.  When  such  an  operation  is  called  for,  it  is 
probably  always  better  to  castrate  and  sew  up  the  abdominal  ring  with 
catgut,  thus  curing  the  immediate  trouble,  ridding  the  patient  of  an 
incessant  annoyance,  and  effecting  a  radical  cure  of  the  hernia. 

Thomas  Annandale,*  July  5, 1877,  replaced  in  the  scrotum  a  testi- 
cle which  was  abnormally  situated  in  the  perineum  of  a  boy  three 
years  old.  The  scrotum  was  opened,  the  testicle  liberated  by  incis- 
ions, replaced  in  the  scrotum,  and  retained  there  by  a  suture  of  cat- 
gut. The  operation  succeeded  fully.  Curling  relates  a  similar  case, 
except  that  he  did  not  suture  the  testicle  to  the  bottom  of  the  scro- 
tum, and  the  operation  failed.  James  Adams  f  has  operated  success- 
fully. John  Wood  J  replaced  a  testicle  which  he  found  in  the  ingui- 
nal canal.  He  everted  the  scrotum  and  sutured  the  testicle  to  it. 
The  patient  recovered  and  was  discharged  wearing  a  truss  having  a 
water-pad.  Wood  *  is  also  credited,  in  a  case  where  he  found  the 
cord  too  short,  with  having  stretched  the  cord,  dissected  the  vas  def- 
erens from  the  globus  major,  and  inverted  the  testicle,  thus  placing  it 
safely  within  the  scrotum.  Max  Schliller  ||  replaced  from  the  ingui- 
nal canal  the  testicle  of  a  youth  of  twenty,  closing  the  external  ring 
by  suture.  Schliller  refers  to  unsuccessful  operations  by  Eosenmerkel 
and  Chelius.  The  best  present  conclusion,  therefore,  is  :  If  the  testi- 
cle is  in  the  inguinal  canal  and  can  be  brought  out  by  manipulation, 
retain  it  there  by  a  suitable  truss.  If  it  is  in  the  canal  and  can  not 
be  brought  out,  a  truss  can  not  be  worn  with  any  advantage,  unless 
it  have  a  cup-shaped  pad,  and  the  choice  lies  between  letting  it  alone 
until  something  happens — which  is  hardly  surgical — or  cutting  down 
upon  it  and  attempting  to  replace  it  in  the  scrotum.     This  can  be 

*  "Edin.  Med.  Journ.,"  January,  1878. 

f  "Lancet,"  1871,  May  27th,  Part  I,  p.  710. 
X  "Lancet,"  May  1,  1880,  p.  681. 

*  "  St.  Louis  Med.  and  Surg.  Journ.,"  June,  188-t,  citing  "  Australian  Medical  Gazette." 
II  "Ann.  of  Anat.  and  Surg.,"  Sept.,  ISSl,  p.  89. 


3GS  DISEASES  OF  THE  TESTICLE. 

done  if  the  cord  is  long  enough.  If  the  cord  is  too  short,  the  oper- 
ator must  be  prepared  to  castrate  and  close  the  ring  and  canal  wi£li 
catgut  sutures,  operating  antiscptically. 

LUXATION    OF    THE    TESTICLE. 

Occasionally  the  testicle  is  dislocated.  In  one  case  reported,*  the 
right  testicle  was  suddenly  and  violently  drawn  up  into  the  inguinal 
canal  during  masturbation,  and  did  not  come  down  again.  Later  in 
life,  when  the  patient  died,  this  testicle  was  found  soft,  atrophied, 
pulpy,  about  one  fifth  the  size  of  its  fellow.  P.  Bruns  f  records  the 
case  of  a  man  run  over  while  lying  on  his  back.  The  right  testicle 
was  dislocated  over  the  pubis  at  the  root  of  the  penis.  It  remained 
there  and  did  not  atrophy.  He  refers  to  other  traumatic  dislocations, 
one  under  the  skin  of  the  thigh  (the  testicle  atrophied),  and  a  num- 
ber where  the  luxation  was  into  the  inguinal  canal. 

HYPERTROPHY    AND    ATROPHY. 

The  testicle  becomes  hypertrophied  conservatively  when  its  fellow 
is  defective  or  wanting,  and  in  certain  lusty  individuals  the  testicles 
are  abnormally  large. 

Atrophy  of  the  organ  may  result  from  a  variety  of  conditions. 
The  retained  testicle  in  a  monorchid  does  not  develop  fully,  and  may 
atrophy.  In  hot  climates  the  organ  is  said  to  atrophy  (Larrey),  as  it 
does  normally  in  old  age.  Atrophy  may  come  on,  usually  attended 
by  neuralgia,  after  prolonged  sexual  excesses,  or  may  succeed  sudden 
pain  after  fatigue.  Probably  some  inflammatory  element  is  at  the 
bottom  of  this  cause. 

Lemmonier  J  records  the  case  of  a  man  of  nineteen,  who  after  a 
severe  injury  to  the  skull  suffered  rapid  atrophy  of  the  right  testicle 
(with  hemiplegia,  etc.).  Kelaton  and  others  have  spoken  of  atrophy  of 
the  testicle  resulting  from  causes  acting  at  a  distance.  Lereboullet  * 
saw  a  case  in  tlie  Val-de-Grace  where  double  atrophy  of  the  testicles 
from  mumps  was  accompanied  by  a  simultaneous  development  of  the 
mammae  in  a  man  of  twenty-two.  True  orchitis  (inflammatory)  or 
the  form  complicating  mumps  may  be  attended  by  atrophy.  Mumps 
usually  spares  the  testicle  before  puberty,  and  even  after  puberty, 
when  the  testicle  is  implicated,  only  partial  atrophy  or  no  atrophy  at 
all  may  follow.  I  have  thought  that  the  rather  free  internal  use  of 
jaborandi  lessens  the  probability  of  atrophy  when  the  testicle  is  at- 
tacked in  mumps. 

*  "  Med.  Times  and  Gazette,"  vol.  xviii,  p.  67. 

f  "  Mittheilungen  aus  der  chir.  Klinik  zu  Tubingen,"  Heft  3,  p.  483,  1884, 
X  "France  Medicale,"  December  25,  1884. 

*  Quoted  in  "Hays's  Monthly  Abstract,"  October,  1877,  p.  462. 


nYPERTROPHY— WOUXDS.  369 

True  orchitis,  or  the  form  comjtlicating  mumps,  is  liable  to  be 
followed  by  atrophy.  Any  tumor  or  morbid  growth  pressing  on  the 
testicle,  or  obstructing  its  vascular  supply,  may  cause  atrophy,  e.  g., 
ligation  of  spermatic  artery,  aneurism  of  aorta  involving  the  spermatic 
arteries  (Wardrop's  case)  ;  in  certain  rare  cases,  hydrocele,  large  con- 
genital hernise,  varicocele,  may  act  in  this  way.  A  section  of  the 
nerves  of  the  testicle  will  cause  atrophy,  as  may  also  certain  injuries 
of  the  head,  back,  or  spinal  cord.  Ligation  of  all  the  veins  of  the 
cord  produces  atrophy.  Atrophy  sometimes  attends  severe  neuralgia, 
especially  the  form  accompanying  large  varicocele.  Non-use  of  the 
testicle  for  any  length  of  time  does  not  cause  it  to  atrophy.  The 
somewhat  common  belief  that  the  long-continued  use  of  iodine  will 
occasion  atrophy  of  the  healthy  testicle  is  incorrect.  Occasionally  in 
children  the  testicles  will  cease  to  develop,  or  even  atrophy,  without 
any  apparent  cause.  Syphilis  may  occasion  atrophy,  without  any 
gummy  deposit. 

Treatment. — For  atrophy  of  the  testicle  there  can  be  but  little 
done.  The  causes  are  usually  beyond  the  surgeon's  control.  In  cer- 
tain cases  the  cause  (neighboring  tumor,  syphilis)  may  be  removed. 

CONTUSIONS    OF    THE    TESTICLE. 

Contusions  of  the  testicle  are  rare,  owing  to  the  peculiar  anatomi- 
cal surroundings  of  the  organ,  notwithstanding  its  exposed  position. 
In  severe  contusions  there  is  usually  more  or  less  ecchymosis,  and  per- 
haps hrematocele  or  orchitis,  and  subsequent  atrophy  may  result. 
One  of  the  modes  formerly  adopted  in  the  East  for  emasculating  the 
attendants  of  the  harem  was  that  of  squeezing  the  testis,  and  a  simi- 
lar plan  has  been  resorted  to  upon  animals,  instead  of  castration,  in 
England  and  France  (Curling).  The  inflammation  after  injury  may 
be  sufficiently  severe  to  lead  to  the  formation  of  abscess  or  to  gan- 
grene. 

Treatment. — The  patient  must  be  placed  at  once  upon  his  back, 
if  the  contusion  be  severe,  with  the  testicle  elevated  and  covered  with 
a  cooling  application  ;  if  subsequent  inflammation  occur,  it  must  be 
met  appropriately  (orchitis). 

WOUNDS    OF    TESTICLE. 

Punctured  wounds,  if  small,  are  of  no  importance.  They  give 
rise  to  no  inconvenience  and  heal  without  trouble.  Penetrating 
wounds  of  any  size,  however,  allow  some  of  the  tubular  structure  of 
the  testis  to  escape.  This,  projecting  outside  and  covered  with  pus, 
is  very  apt  to  be  mistaken  for  a  core  of  pus,  and  to  be  pulled  out  as 
such.  Malgaigne  mentions  a  case  where  he  saw  the  whole  pulp  of  the 
24 


370  DISEASES   OF  THE   TESTICLE. 

organ  pulled  oxit  in  tliis  way.  Incised  wounds  are  followed  by  suppu- 
ration, partial  exulceration,  and  recovery,  with  more  or  less  atrophy. 
Injuries  to  the  testicle  (contusions  or  wounds)  are  usually  very  pain- 
ful in  sensitive  subjects,  and  are  liable  to  be  conii)licated  at  the  time 
with  faintness,  nausea,  vomiting,  convulsions,  or  tonic  s]iasnis. 

Treatment. — In  wounds  of  the  testicle,  if  there  be  any  true  hernia 
of  the  secreting  substance,  it  should  be  reduced  if  possible,  and  re- 
tained by  pressure,  or  by  a  suture  through  the  tunica  albuginea.  If 
it  can  not  be  reduced,  it  may  be  snipped  off  with  the  scissors,  or  al- 
lowed to  separate  by  the  natural  inflammatory  process,  but  should  in 
no  case  be  pulled  upon.  Large  incisions  should  be  cleaned,  united  by 
suture,  and  the  parts  carefully  supi)orted.  Even  if  a  large  part  of 
the  testicle  has  been  destro^'cd  by  the  accident,  an  effort  should  be 
made  to  preserve  what  is  left.  Dorsal  decubitus  must  be  preserved, 
and  the  testicle  properly  supported.  Cool  water-dressing  is  as  good  as 
any  that  can  be  emjiloyed,  perhaps  mingled  with  a  little  alcohol  or 
carbolic  acid. 

HEMATOCELE. 

The  term  ha^matocele  is  applied  to  a  tumor  caused  by  the  effusion 
of  blood  into  the  sheath  of  the  testicle  and  cord  (sometimes  into  the 
cellular  tissue  of  the  scrotum  as  well),  into  the  tunica  vaginalis,  or 
into  a  pre-existing  cyst  of  the  cord.  It  is  usually  of  traumatic  origin, 
or  is  a  secondary  affection  occurring  where  hydrocele  has  preceded  it 
by  a  mingling  of  blood  with  the  serous  contents  of  the  tuiiior. 

The  most  common  cause  is  violence,  associated  with  crushing  of 
tissue  and  injury  of  blood-vessels.  An  operation  u})on  a  hydrocele 
may  wound  a  vessel  or  the  testicle  itself,  and,  if  the  haemorrhage 
takes  i^lace  internally,  a  hrematocele  results.  The  disease  may  ex- 
ceptionally have  a  spontaneous  origin  from  active  or  passive  hypere- 
mia ;  varicose  scrotal  or  seminal  veins  connected  with  great  laxity  of 
the  scrotum  ;  or,  rarely,  from  a  luTmorrhagic  secretion  in  scorbutic 
individuals.  Sir  Benjamin  Brodie  *  mentions  as  a  cause  a  diseased 
(calcareous)  condition  of  the  arteries  distributed  upon  the  tunica  albu- 
ginea, similar  to  the  degeneration  of  the  arteries  of  the  brain  which 
often  precedes  apoplexy.  One  of  them  may  rupture  into  the  tunica 
vaginalis. 

There  are,  consequently,  two  varieties.  The  one  coming  on  rap- 
idly, usually  after  injury,  and  attended  by  effusion  of  blood  into  the 
scrotum,  where  the  latter  suddenly  swells,  becomes  blue,  black,  or  vio- 
let-colored, with  a  more  or  less  evident  feeling  of  fluctuation,  or  where 
a  pre-existing  cyst  or  hydrocele,  after  violence,  becomes  suddenly 
larger,  more  tense,  and  painful.  There  is  more  or  less  high  sympto- 
matic fever,  and  the  inflammation  may  possibly  go  on  to  suppuration. 

*  "  London  Medical  Gazette,"  vol.  ix,  p.  927. 


n^JIATOCELE— CAUSES. 


371 


In  the  other,  or  spontaneous  variety,  the  tumor  increases  slowly  in 
size  and  simulates  hydrocele,  except  in  regard  to  transluccncy.  This 
latter  form  is  difficult  to  diagnose  from  hydrocele  in  proportion  as  the 
blood  is  thin  and  confined  to  the  tunica  vaginalis  propria. 

The  blood  in  hsematocele  may  be  found  red  and  fluid,  but  it  is  usu- 
ally black  or  brown,  and  may  be  mixed  with  pus,  if  severe  inflamma- 
tion has  followed  its  effusion.  Its  fibrinous  portions  may  be  more  or 
less  stratified,  as  in  aneurism.  The  walls  of  the  tunica  vaginalis,  or 
of  a  cyst  in  contact  wrih  blood  (unlike 
what  occurs  when  their  contents  are 
serous),  tend  to  thicken  and  become 
adherent  to  the  surrounding  connective 
tissue,  while  the  inner  surface  becomes 
rough  and  uneven,  resembling  anything 
more  than  a  serous  surface  (Fig.  106). 
The  walls  of  hasmatocele  have  been 
found  an  inch  thick. 

The  diagnosis  of  h?ematocele  of  the 
second  or  spontaneous  variety  presents 
many  difficulties.  Here  there  is  no 
guide  in  any  discoloration  of  the  scro- 
tum, or  any  suddenness  of  growth  of 
the  tumor.  The  records  of  surgery  pos- 
sess many  cases  where  perfectly  healthy 
testes,  surrounded  by  a  hsematocele  in- 
side of  a  thickened  tunica  vaginalis,  have  been  extirpated,  under  the 
idea  that  they  were  cancerous.  Often  there  exists  no  positive  means 
of  diagnosis  short  of  an  exploratory  operation  with  the  knife,  which 
is  the  proper  course  to  follow  in  such  cases.  There  are,  however, 
characteristics  of  hsematocele  which  may  serve  to  distinguish  it  from 
hydrocele  and  malignant  growths. 

The  pyriform  shape  of  hydrocele  exists,  but  there  is  no  translu- 
ccncy of  the  tumor.  This,  however,  would  also  be  the  case  in  an  old 
hydrocele  with  thickened  walls.  The  mass  feels  unusually  heavy 
when  balanced  in  the  hand.  If  it  has  been  attentively  watched,  it 
will  be  found  to  have  decreased  a  little  in  size  at  some  period  of  its 
growth,  which  does  not  occur  in  malignant  disease.  The  peculiar 
sensibility  produced  by  pressure  on  the  testicle  can  often  be  called  out 
by  pressing  upon  the  mass  behind,  at  about  the  middle  portion.  Ex- 
ploration with  the  aspirator  and  a  good-sized  exploring-needle  will 
clear  up  the  diagnosis.  The  amount  of  pain  is  variable.  The  general 
health  does  not,  as  a  rule,  suffer  much.  In  a  doubtful  case  an  ex- 
ploratory incision  is  demanded. 

In  the  traumatic  variety,  when  the  blood  has  been  effused  into  the 
connective  tissue  of  the  scrotum,  the  diagnosis  is  made  at  once  by  the 


Fig.  106  {Curling). 


372  DISEASES   OF  THE   TESTICLE. 

history,  size,  heat,  and  color  of  the  tumor.  Tliis  is  more  strictly  con- 
tusion with  effusion  of  blood,  and  not  true  lutMnatocele  ;  but  it  may 
accompany  the  latter  condition  when  due  to  violence. 

2'rcatinent. — In  acute  cases  all  that  can  be  done  is  to  keep  the 
patient  upon  his  back,  with  the  testicle  sujiportcd  and  covered  with 
cold  lotions,  administering  j)eriiaps  an  occasional  laxative  and  an  ano- 
dyne if  the  pain  be  severe.  If  the  quantity  of  blood  effused  is  not  too 
great,  the  pain  will  soon  begin  to  subside,  and  the  ]iatient  may  be  al- 
lowed to  go  about  with  a  suspensory  bandage.  The  blood  will  gradu- 
ally be  absorbed. 

If,  in  spite  of  these  means,  which  will  rarely  be  found  to  fail,  blood 
continues  to  be  poured  out  into  the  cavity  so  that  the  pain  becomes 
excessive,  and  the  tension  of  the  parts  very  great,  a  trocar  may  be  in- 
troduced to  draw  off  the  blood,  and  cold  and  pressure  applied  to  pre- 
Tent  refining  of  the  sac.  If  it  fills  again,  a  second  tapping,  delayed 
as  long  as  possible,  will  probably  afford  a  more  serous  fluid  than  the 
first,  and  a  third,  a  fluid  still  less  tinged,  after  which  radical  treat- 
ment by  injection  may  be  attempted. 

When,  however,  the  blood  is  in  clots,  it  will  not  flow  through  a 
trocar,  and  then  an  incision  may  be  required,  as  it  is  also  when  the 
inflammation  is  imminent  from  tension.  All  the  clots  should  be 
turned  out,  the  cavity  thoroughly  washed  with  a  mild,  warm  solu- 
tion of  carbolic  acid,  or  other  antise])tic  lotion  ;  bleeding-points 
should  be  looked  for  and  secured  by  ligature.  Damaged  and  redun- 
dant portions  of  the  tunica  vaginalis  may  be  cut  away,  and,  after  thor- 
ough antiseptic  irrigation,  the  sides  of  the  tunica  vaginalis  may  be 
attached  by  suture  to  the  sides  of  the  scrotal  incision  (Volkmann's 
method),  the  cavity  drained  and  dressed  antiseptically. 

In  incising  the  tunica  vaginalis  an  opening  should  fii'st  be  made 
above  and  in  front,  and  this  should  be  continued  on  a  director,  or  be- 
tween two  fingers,  fairly  to  the  bottom  of  \hQ  sac,  to  secure  good 
drainage.  If  the  incision  be  made  at  one  stroke,  the  testicle,  which  is 
sometimes  misplaced  and  lies  in  front,  may  be  laid  open,  an  accident 
which  has  happened  in  the  most  experienced  hands.  If  the  tunica 
vaginalis  in  an  old  case  be  found  much  thickened,  it  is  better  to  cut  it 
away — invariably  if  its  walls  contain  calcareous  plates. 

The  reaction  following  operation  is  rapid  and  severe,  and,  in  the 
case  of  old  patients,  it  may  sometimes  be  preferable  to  perform  castra- 
tion, as  the  milder  alternative.  With  the  young  and  middle-aged, 
however,  this  course  is  not  to  be  thought  of,  as  the  testicle  is  seldom 
injured,  although  in  long-standing  cases  it  is  occasionally  atrophied. 
Erysipelas  or  gangrene  may  follow  the  laying  open  of  hematocele. 
A  haematocele  produced  by  the  effusion  of  blood  into  a  pre-existing 
hydrocele  may  usually  be  treated  like  uncomplicated  hydrocele.  Any 
systemic  state  predisposing  to  haemorrhage  requires  special  manage- 


HEMATOCELE— TREATMENT. 


o  <  o 


ment,   and  all  operative  interference  should  be  delayed  until  such 
blood-dyscrasiae  have  been  removed. 

H.^MATOCEIiE   OF   THE   CORD. 

Pott  has  described  a  diffused  haematocele  of  the  cord  coming  on 
during  straining  at  lifting  or  at  stool,  and  confined  within  the  tunica 
vaginalis  communis.  This  form  is  exceedingly  rare.  It  may  occur, 
also,  in  connection  with  general  ecchymosis  of  the  scrotum  from  injury, 
and  calls  for  the  same  treatment.  The  blood  will  be  reabsorbed  in 
time.  It  has  been  confounded  with  hernia,  and  operated  on  as  such. 
If  the  tumor  continue  to  enlarge  in  spite  of  position,  rest,  and  cool- 
ing applications,  a  free  incision  should  be  made,  the  clots  turned  out, 
the  wound  washed,  and  the  bleeding  vessel  sought  for  and  secured. 

When  an  encysted  hydrocele  of  the  cord,  by  accident  or  dyscrasial 
disease,  becomes  a  htematocele,  the  same  changes  take  place  in  the 
walls  of  the  sac  and  surrounding  tissue  as  have  been  described  in 
haematocele  of  the  tunica  vaginalis.  The  treatment  is  also  the  same, 
care  being  always  taken  to  treat  the  dyscrasial  causative  condition. 

FREE   BODIES   IN"   THE   TUNICA   VAGINALIS. 

Occasionally  little  excrescences  spring  up  from  the  surface  of  the 
testicle  within  the  cavity  of  the  tunica  vaginalis.  They  may  grow  any- 
where within  the  tunica  vaginalis,  but  are  more  common  on  the  epididy- 
mis or  around  the  so-called  hydatid  of  Morgagni.  These  excrescences 
have  an  inherent  tendency  to  grow  large  at  the  summit  by  a  deposition 
of  concentric  layers  of  very  dense  connective  tissue,  and  thus  become 
pediculated.  New  excrescences  may  form  upon  an  old  one,  constituting 
a  sort  of  dendritic  vegetation.  There  is  a  tendency  to  a  central  deposit 
of  calcareous  salts  early  in  the  formation  of  these  little  pedunculated 
balls,  which  causes  an  arrest  in  their  growth.  After  this  the  pedicle 
becomes  more  and  more  thin,  and  finally  breaks  and  disappears  in  some 
motion  given  to  the  testicle.  In  this  way  are  the  free  bodies  formed. 
They  are  found  of  all  sizes,  from  the  head  of  a  pin  to  a  large  hazel-nut. 
They  are  not  encountered  in  connection  with  very  large  hydroceles, 
although  some  fluid  in  the  tunica  vaginalis  usually  accompanies  them. 
They  may  often  be  felt  from  the  outside,  and  be  liberated  at  once  by  an 
incision  if  they  cause  pain  or  inconvenience  ;  which,  however,  they  sel- 
dom do.  Occasionally  after  tapping  a  hydrocele  great  pain  has  been 
complained  of,  which  has  been  found  to  be  connected  with  the  existence 
of  a  loose  body  in  the  sac.  In  structure  these  bodies  consist  of  con- 
centric layers  of  very  dense  fibrous  tissue,  cartilaginous  to  the  feel,  sur- 
rounding a  central  nucleus  of  calcareous  matter.  An  attentive  inspec- 
tion of  the  surface  of  the  testicle  will  often  show  prominences  or  de- 
pressions corresponding  to  the  points  where  the  free  bodies  had  been 
attached  by  their  pedicles. 


374  DISEASES  OF  THE  TESTICLE. 


CHAPTER  xxin. 

DISEASES  OF  THE  TESTICLE. 

Hydrocele,  acnte,  chronic.— Dinrrnostic  Table  of  Chronic  Hydrocele  with  Incarcerated  Ilcmia.— Pal- 
liative Treatment. — Itjulical  Treatment.— C(>nj;enital  Hydrocele.— Dia-iiiostic  Table  of  t'ongeni- 
tal  Hydrocele  and  Hernial  Tumor.— Trne  and  Spurious  Hydrocele  of  Hernial  Sac— Encysted 
Hydrocele  of  Testis.— Spermatocele.— Spermatic  Congestion.— Origin  of  Spermatocele.— Hydro- 
cele of  Cord,  diffuse,  encysted. 

Hydrocele,  or  dropsy  of  the  testicle,  consists  in  an  accnniultitioii 
of  serous  tluid  within  the  cavity  of  the  tunica  vaginalis  (simple  hydro- 
cele), or  Avithin  a  cyst  connected  with  the  testicle  (encysted  hydrocele). 
This  fluid  is  usually  highly  albuminous  and  of  a  pale-yellow  color,  hut 
it  may  vary  through  shades  of  red,  brown,  green,  and  black,  by  the 
admixture  of  more  or  less  blood,  or  blood-pigment,  and  in  old  cases 
the  fluid  may  contain  fatty  matter  and  plates  of  cholesterine,  granular 
bodies,  pus,  epithelium,  and  occasionally  spermatozoa  (spermatic 
hydrocele).  The  fluid  differs,  both  in  its  nature  and  mode  of  pro- 
duction, from  that  of  general  anasarca.  In  anasarca  the  scrotum  may 
be  full  and  the  tunica  vaginalis  empty.  The  liquid  of  hydrocele  often 
contains  a  substance  similar  to  fibrin.  On  exposure  to  the  air  under 
these  circumstances,  it  will  generally  deposit  in  one  or  several  layers. 
Buchanan,  of  Glasgow,  found  that  if  blood  were  mingled  with 
the  fluid  it  coagulated,  when  by  contact  of  air  alone  it  would  not  do 
so.  Alexander  Schmidt  produced  the  same  coagulation  by  adding 
blood-globules  or  hgemato-crystallin.  The  fluid  sometimes  contains 
salts  and  albuminates  in  a  proportion  analogous  to  that  of  lytn])h — 
which  never  obtains  in  the  fluids  of  simple  dropsies  (Virchow).  Chy- 
locele*  is  the  name  given  to  the  hydrocele  in  certain  cases.  Vidal  de 
Cassis  first  described  this  affection,  calling  it  galactoccle.f  Buscy  calls 
it  chylous  hydrocele,  and  Claudius  Mastin,  chylocele.  William  Mastin 
cites  the  cases  of  Vidal,  Euthnum,  Ferguson,  and  C.  H.  Mastin,  and 
adds  his  own,  a  fifth  case,  in  which,  and  in  0.  H.  Mastin's  case,  incis- 
ion effected  a  cure.  In  both,  a  projecting  point,  believed  to  be  the 
offending  lymph-vessels,  which  leaked,  was  ligated  and  cut  awtiy.  Ty- 
son, of  Philadelphia,  examined  the  fluid  in  both  instances,  and  found 
it  to  resemble  chyle  ;  alkaline,  1015-1018,  albuminous,  full  of  mole- 
cules and  small  granular  cells.  Ether  dissolved  the  fat,  which  after- 
ward on  evaporation  offered  a  cream-like  mass.  In  one  of  the  cases 
there  were  a  few  spermatozoa. 

*  W.  H  Mastin,  "Ann.  of  Anat.  anl  Surg.,"  May,  1882,  p.  223. 

f  "Traite  de  Pathologic  et  do  Med.  operatoirc,"  5tb  edition,  vol.  v,  18G1,  p.  180. 


nYDROCELE. 


y/ib 


Another  form  is  that  of  multilocnlur  hydrocele,  christened  lymph 
angioma  by  Steinthal,*  and  consists  of  a  main  sac,  a':  the  botUnn  (jf 
which  are  many  small  ones,  the  largest  as  big  as  a  cherry,  containing 
clear,  white  fluid.  Steinthal  thinks  the  cysts  are  developed  out  of 
dilated  lymph-vessels.     They  are  lined  with  endothelium. 

Cause  of  Hydrocele. — In  the  aged,  anaemic,  weak,  and  badly 
nourished,  there  may  be  a  chronic  dropsy  of  the  tunica  vaginalis, 
the  cause  of  which  is  simply  general  hydrasmia  ;  there  are  usually 
other  serous  effusions  existing  at  tlie  same  time.  Thin  condition  is 
a  general  one,  and  no  special  attention  need  be  paid  to  the  hydro- 
cele, except  the  wearing  of  a  suspensory  bandage,  until  the  general 
health  is  restored,  after  which  it  would  be  proper  to  undertake  a  radi- 
cal cure,  if  the  hydrocele  did  not  spontaneously  subside.  In  excep- 
tional cases,  when  the  collection  of  fluid  becomes  excessive,  palliative 
puncture  may  be  resorted  to.  A  slight  amount  of  hydrocele  exists,  as 
a  rule,  in  conjunction  with  all  diseases  of  the  testicle,  especially  of  the 
inflammatory  sort  (orchitis,  epididymitis),  and  not  infrequently  with 
syphilitic  and  tubercular  disease  of  the  organ.  But  in  these  cases 
again  the  hydrocele  is  only  a  symptom,  and  a  radical  cure  should  not 
be  attempted.  When  the  disease  of  the  testicle  subsides,  the  hydrocele 
will  get  well. 

True  hydrocele  is  the  result  of  a  secretory  irritation  of  the  tunica 
vaginalis  testis,  produced  usually  by  mechanical  violence,  or  in  sym- 
pathy with  some  irritation  of  the  testicle,  cord,  or  urethra.  The 
mechanical  violence  most  apt  to  produce  it  is  such  as  is  slight,  irrita- 
tive, and  long  continued  ;  rubbing,  jolting,  crushing.  In  warm  cli- 
mates it  is  very  frequent,  on  account  of  the  relaxed  condition  of  the 
scrotum,  which  exposes  the  testicle  to  injury.  In  Brazil  one  man  in 
every  ten  is  said  to  suffer  from  hydrocele  (Hyrtl).  Hydrocele  may  be 
left  behind  after  an  acute  inflammation  of  the  testis,  and,  in  those 
exceptional  cases  where  the  communication  of  the  tunica  vaginalis 
with  the  peritoneal  cavity  has  not  been  closed  after  birth,  a  hydro- 
cele is  known  as  conoeuital. 


ACUTE    HYDROCELE. 

This  is  an  acute  peripheral  orchitis,  coming  on  in  connection  with 
acute  epididymitis  or  orchitis,  and  needs  no  detailed  account.  The 
condition  is  analogous  to  pleurisy.  The  effusion  is  rapid,  sero-plastic, 
or  sero-hcemorrhagic.  The  fluid  is  absorbed,  as  a  rule,  while  the 
inflammation  of  the  testicle  is  subsiding,  and  no  treatment  is  of  any 
service  before  that  time,  unless,  possibly,  puncture,  if  the  effusion  be 
very  large. 

*  "CntiToltt.  f.  Chirurgic,"  October  10,  1SS5,  and  Hays's,  "International  Journal," 
January,  18S6,  p.  283. 


376  DISEASES  OF  THE  TESTICLE. 

It  is  always  caused  in  a  mild  degree  by  the  stimulating  injections, 
or  other  treatment  used  for  the  cure  of  chronic  hydrocele,  and  may 
occur  idio})athically  Avithout  necessary  connection  with  other  inflam- 
matory disease  of  the  testicle,  but  this  is  exceedingly  rare.  Rest  with 
cooling  lotions,  and  acupuncture,  if  necessary,  constitute  the  treat- 
ment. 

CHRONIC    HYDROCELE. 

In  chronic  hydrocele,  the  effusion  takes  place  slowly,  and  without 
pain.  The  swelling  is  often  only  discovered  by  accident.  It  com- 
mences in  the  lower  part  of  the  testicle  in  front.  It  has  no  tendency 
to  spontaneous  subsidence.  The  accumulation  of  fluid  tends  to  go  on 
indetinitely,  with  occasional  periods  of  quiet,  until,  in  some  cases,  an 
enormous  size  is  reached.  The  amount  of  fluid  may  be  only  a  few 
drachms.  It  seldom  exceeds  a  pint.  Curling  met  witli  one  case 
which  contained  forty-eight  ounces.  Sixty-four  ounces  were  taken 
from  one  (personal)  case.  Mr.  Cline  is  said  to  have  removed  as  much 
as  six  quarts  from  the  historian  Gibbon  (Sir  Astley  Cooper).  Out  of 
a  thousand  cases  reported  by  Dr.  Dujat,  from  the  Hospital  of  Cal- 
cutta, in  eighteen  the  quantity  drawn  off  varied  from  fifty  to  one 
hundred  and  twenty  ounces  for  each  case.  The  mechanical  incon- 
venience of  such  a  tumor  in  such  a  position  is  at  once  apparent. 

When  a  hydrocele  has  lasted  for  a  length  of  time,  its  walls  arc 
liable  to  a  fibrous  thickening,  which  greatly  obscures  the  diagnosis,  or 
they  may  undergo  cartilaginous  or,  more  rarely,  calcareous  degenera- 
tion. If  subjected  to  irritation  or  repeated  injury,  which  can  hardly 
be  avoided,  these  changes  are  all  the  more  apt  to  occur.  The  con- 
tents of  hydrocele  may  be  mixed  with  blood,  or  even  become  puru- 
lent. Secondary  cysts  may  form  in  or  upon  the  surface  of  the  testicle, 
surrounded  by  the  fluid  of  the  hydrocele,  but  this  is  rare.  Long- 
continued  pressure  of  the  fluid,  especially  when  the  tunic  is  thickened 
and  covered  with  lymph,  occasional!}',  but  very  rarely,  leads  to  atrophy 
of  the  testicle.  Points  of  adherence  may  exist  between  the  two  sur- 
faces of  the  tunica  vaginalis,  dividing  the  cavity  into  compartments. 

Si/m/>ioms.  —Hydrocele  is  usually  pear-shaped,  larger  below  than 
above  ;  or  it  may  be  oval,  and,  if  very  large,  almost  spherical.  It  can 
not  be  reduced  by  pressure.  Fluctuation  can  usually  be  made  out. 
The  tumor  is  generally  very  tense,  the  scrotum  often  stretched  and 
shining.  The  cord,  of  natural  size  and  feel,  can  be  grasped  above  the 
tumor.  The  weight  is  slight  compared  with  the  size  of  the  mass. 
The  testicle  is  usually  situated  behind,  a  little  below  the  center  (Fig. 
107),  and  pressure  on  this  point  gives  rise  to  the  peculiar  sensation 
experienced  when  the  testicle  is  squeezed.  Occasionally  the  testicle  is 
found  below  and  in  front,  more  rarely  in  the  center,  in  front,  from 
plastic  adhesion.     Its  position  should   always  be  ascertained  before 


HYDROCELE. 


377 


operating  on  a  hydrocele.  Dupuytren  mentions  several  cases  where 
this  precaution  was  overlooked,  the  testicle  was  wounded  and  the 
diagnosis  unconfirmed.  If  the  testicle  be  punctured,  as  a  rule  no 
serious  inflammation  results.  Pressure  on  a  hydrocele  does  not  pro- 
duce pain  ;  there  is  no  heat  or  redness 
of  the  skin,  unless  the  tumor  be  large 
enough  to  keep  it  constantly  on  the 
stretch.  There  is  flatness  on  percus- 
sion, differing  from  hernia,  and  there 
is  no  subjective  symptom  except  a 
little  dragging  sensation  in  the  groin 
and  lower  part  of  the  abdomen,  run- 
ning up  to  the  back,  caused  by  the 
weight  of  the  tumor. 

Diagnosis.  —  The  infallible  diag- 
nostic sign  is  translucency.  This  is 
obtained  by  making  the  skin  tense 
over  the  tumor,  and  viewing  a  lighted 
candle,  held  as  near  the  tumor  as  pos- 
sible, through  the  upper  part  of  the 
swelling,  shading  the  eye  with  the 
hand,  or,  better  still,  looking  through 
a  cylindrical  roll  of  paper,  or  a  stetho-  Fig.  107  {Potf). 

scope.     If    the    room    be    darkened, 

translucency  may  be  detected  where  otherwise  the  test  might  fail. 
Often  translucency  may  be  made  out  by  simply  making  the  tumor 
tense  with  one  hand,  shading  the  eye  with  the  other,  and  holding  the 
hydrocele  between  the  eye  and  the  window,  in  the  daytime.  Trans- 
lucency is  greater  in  proportion  to  the  slowness  of  the  accumulation, 
the  thinness  and  whiteness  of  the  walls,  and  the  limpidity  of  the  fluid. 
If  the  contents  of  the  tumor  are  dark-colored,  or  its  walls  very  dense 
and  thick,  there  will  be  no  translucency. 

In  such  a  case  exploratory  puncture  will  decide  on  the  nature  of 
the  tumor.  A  fine  exploring  trocar  should  be  used  with  an  aspirator. 
Few  diseases  are  easier  of  detection  than  simple,  uncomplicated  hydro- 
cele ;  few  more  difficult  where  many  complications  exist.  Varicocele 
may  compliccite  hydrocele. 

To  recapitulate  :  the  symptoms  of  simple  hydrocele  aie  pyriform 
shape,  slow  growth,  commencing  at  the  bottom  of  the  scrotum,  fluc- 
tuation, translucency — all  with  absence  of  pain. 


DIAGNOSTIC   TABLE-HYDROCELE-INCARCEIIATED   HERNIA. 


Hijdrocde. 

1.  Largest  below. 

2.  Commences  gradually. 


Incarcerated  Hernia. 

1.  Largest  above. 

2.  Comes  on  suddenly. 


378 


DISEASES  OF  THE  TESTICLE. 


ffi/droeelc. 
8.  Commences   at   the  bottom    of   tlie 
scrotum,  anil  grows  up. 

4.  Is  tense  or  fluctuating. 

5.  Cord  can  be  maile  out  (normal)  above 
tumor. 

0.  Testicle  can  not  be  founJ. 

1.  Dullness  on  percussion. 

8.  Tumor  heavy,  but  movable. 

9.  KeJuction  impossible. 

10.  Size  usually  constant. 

11.  Test    by    aspiration    completes   the 
diagnosis. 


Incarcerated  Hernia. 
8.  Commences  at  the  external  ring  and 
grows  down. 

4.  Usually  doughy. 

5.  Cord  can  not  be  distinguished,  or  is 
felt  as  distinct  from  tumor. 

6.  Testicle    can    usually    be    separated 
from  tumor  posteriorly. 

7.  Resonance  on  percussion  (unless  her- 
nia be  omental). 

8.  Tumor  unwieldy. 

9.  Ilcduction  impossible. 

10.  Size  varies  at  short  intervals. 


Simple  hydrocele  may  be  complicated  with  incarcerated  or  simple 
heruia  (Fig,  108).     True  and  false  hydrocele  of  a  hernial  sac  and  con- 
genital hernia  in  connection  with  hydrocele  will  be  considered  later. 
Absence  of  pain   makes  diagnosis  easy  Avith  all   inflammatory  acute 
maladies.     Smoothness  of  surface  distinguishes 
hydrocele  from  cancer,  cystic  and  tubercular 
disease. 

Treatment  of  Hydrocele. —  Hydrocele  is 
cured  by  causing  the  fluid  to  'be  reabsorbed,  by 
arresting  the  secreting  activity  of  the  tunica 
vaginalis,  or  by  excising  the  walls  of  the  tunic 
by  a  cutting  operation.  Absorption  occurs  oc- 
casionally in  the  young,  and,  as  a  rule,  in  acute 
hydrocele  spontaneousl}'.  The  treatment  is  pal- 
liative and  radical. 

Tapping. — This  is  best  performed  with  the 
aspirator  (using  needle  No.  2,  Dieulafoy).  The 
skin  is  made  tense,  and  the  needle  plunged  into  the  anterior  ]iarfc  of 
the  tumor,  a  little  above  the  middle.  The  testicle  should  be  carefully 
avoided. 

This  simple  operation  will  always  efface  the  tumor  at  once,  but  in 
the  majority  of  instances  the  sac  will  begin  to  refill  in  a  few  days,  and 
after  some  weeks,  or  at  most  months,  will  have  regained  its  i)rcvious 
size.  Sometimes  the  tumor  never  refills,  and  the  palliative  o])eration 
thus  becomes  radical  This  rarely  occurs  except  with  children  and 
very  recent  hydroceles.  The  chances  of  obtaining  this  fortunate  re- 
sult are  greatly  increased  if  the  inside  of  the  sac  be  roughly  scratched 
with  the  point  of  the  exploring  trocar,  after  the  fluid  has  been  drawn 
off.  If  the  patient  is  old  or  greatly  debilitated,  he  should  always 
rest  for  a  few  days  after  tapping.  The  constant  stretching  of  the  skin 
by  a  large  hydrocele  renders  it  prone  to  take  on  gangrenous  inflamma- 


FiG.  108  (.Vaclise). 


HYDROCELE— TREATMENT.  370 

tion.  Sir  Astley  Cooper  mentions  two  cases  of  inflammation  witii 
slouo-hing,  followed  by  death,  in  old  men  who  took  a  long  walk  imme- 
diately after  the  operation.  It  is  well  also,  if  the  collection  of  fluid  is 
very  large,  especially  if  the  patient  is  old,  not  to  draw  it  all  off  at  one 
sitting. 

If  the  testicle  has  been  wounded,  the  patient  will  complain  of  some 
pain,  and  blood  will  flow  after  the  serum  has  been  evacuated.  Under 
these  circumstances  it  is  advisable  to  strap  the  testicle  with  adhesive 
plaster  immediately  after  the  operation,  to  prevent  the  further  effu- 
sion of  blood  into  the  sac,  as  this  is  favored  by  the  removal  of  press- 
ure. Collodion  is  recommended  by  some  authors  to  compress  the 
testicle  in  this  and  other  conditions,  but  it  will  not  do  for  all  cases,  as 
its  application  to  the  thin  and  sensitive  integument  of  the  scrotum 
sometimes  gives  rise  to  exquisite  and  prolonged  torture. 

Acupuncture. — This  consists  in  making  the  skin  tense  over  the 
tumor,  and  penetrating  the  sac  rapidly  a  number  of  times  with  a 
needle,  which  should  be  rotated  as  it  is  being  withdrawn.  The  serum, 
in  cases  so  operated  upon,  gradually  escapes  into  the  scrotum  (in 
twenty-four  to  forty-eight  hours),  where  it  does  no  harm,  and  whence 
it  is  absorbed. 

The  adult  hydrocele  will  usually  fill  up  after  this  operation,  as  it 
will  after  tapping,  but  the  hydroceles  of  children  often  remain  radi- 
cally cured,  especially  if  the  internal  surface  of  the  sac  be  scratched. 
If  the  cyst-wall  be  thick,  and  the  tumor  not  translucent,  neither  tap- 
ping nor  acupuncture  will  ever  effect  a  cure.  Healthy  young  patients 
can  put  on  a  suspensory  bandage  and  resume  work  at  once  after 
tapping  or  acupuncture. 

Radical  Treatment. — External  irritation  or  stimulation  of  the 
skin  will  often  suffice  to  cure  a  simple  hydrocele  in  a  young  child. 
Tincture  of  iodine,  at  about  half  strength,  may  be  used,  or  a  lotion, 
recommended  by  Curling,  of  hydrochlorate  of  ammonia  3],  distilled 
vinegar  3  iv,  water  3  vj  ;  in  fact,  any  mildly  stimulating  ointment  or 
lotion  will  do.  It  is  a  waste  of  time  to  try  this  treatment  upon  the 
adult. 

Although  chronic  hydrocele  has  been  known  to  subside  spon- 
taneously in  the  adult,  yet  this  termination  is  of  so  rare  occurrence 
that  practically  it  may  be  said  never  to  happen.  Sometimes  the  sac 
becomes  ruptured  by  accident,  inflammation  follows,  and  the  cure  is 
permanent.  That  this  is  not  an  inevitable  result  is  proved  by  a  ease 
reported  by  M.  Serres,*  of  a  Spaniard,  who  was  accustomed  to  ride 
horseback,  or  perform  some  other  violent  exercise,  when  his  hydrocele 
became  uncomfortably  large.  In  this  way  he  had  ruptured  it  thirty 
times,  remaining  well  for  a  considerable  period  after  each  application 
of  this  rather  severe  treatment.     Of  the  many  methods  of  treating 

*  Cited  bv  Curling. 


380  DISEASES  OF  THE   TESTICLE. 

simple  hydrocele,  only  two  need  be  detailed,  as  they  are  applicable  to 
all  cases,  nanielv,  injection  and  incision,  inclnding  excision  of  the 
tunica  vaginalis.     Galvano-puncture  failed  in  my  hands. 

Injection. — All  simple  hydroceles  which  are  translucent,  no  matter 
what  tiieir  age  or  how  great  their  size,  are  amenable  to  treatment  and 
cure  by  injection.  Injection  is  not  applicable  to  cases  where  the  con- 
tents of  the  tumor  are  scro-purulent  or  sero-sanguinolent,  or  where  tlie 
tunica  vaginalis  is  extensively  thickened,  with  or  without  calcareous 
deposit.  In  such  cases  incision  cr  excision  should  be  resorted  to. 
Ilvdrocele  complicating  syphilitic  testis  should  generally  be  left  alone 
or  treated  by  palliative  tapping — but  in  one  such  case  I  succeeded  in 
effecting  a  cure  by  the  injection  of  carbolic  acid.  Generally  the  hydro- 
cele accompanying  syphilitic  disease  of  the  testicle  disappears  spon- 
taneously as  the  testicle  grows  better  under  internal  medication. 

Celsus  alluded  to  injections  as  a  method  of  treating  hydrocele,  but 
Munro,  of  Scotland,  Sir  James  Earle,  and  Sir  James  Ranald  Martin, 
of  England,  are  the  names  most  prominently  connected  with  it.  In- 
flation with  air  has  been  employed,  and  the  most  varied  substances 
have  been  used  in  injections,  from  distilled  water  to  the  strongest 
acids,  hot  and  cold.  Many  substances  have  been  employed  success- 
fully, such  as  spirits  of  wine,  port  wine,  solutions  of  alum  or  sulphate 
of  zinc,  air,  chlorine  gas,  lime-water  (Curling),  chloride  of  zinc,  bi- 
chloride of  mercury,  tincture  of  iodine  (Martin),  and  last  and  best 
carbolic  acid.  A  hydrocele  should  not  be  injected  when  first  seen. 
Tapping  should  be  tried  first,  and  perhaps  the  fluid  may  not  rcaccu- 
mulate.  I  have  seen  extensive  inflammation  follow  simple  tapping  on 
two  occasions  in  the  cases  of  old  men.  Both  resulted  in  cure.  When 
the  tumor  is  very  large,  it  is  best  first  to  reduce  its  size  by  one  or 
more  tappings,  and  finally  to  inject  when  the  surface  has  become  con- 
tracted by  being  relieved  from  prolonged  tension. 

If  the  hydrocele  is  found  to  contain  more  or  less  blood,  injection 
should  be  postponed  until  some  future  tapping  yields  a  comparatively 
limpid  fluid.  If  syphilitic  or  tubercular  disease  be  found,  injection  is 
inadmissible,  generally.  I  have  used  many  substances  in  injection 
for  the  radical  cure  of  hydrocele,  and  have  finally  come  to  rely  totally 
upon  pure  carbolic  acid.  It  is  more  certain,  more  speedy,  less  pain- 
ful, and  less  dangerous  than  any  substance  I  have  ever  used.  To  R.  J. 
Levis,  of  Philadelphia,*  belongs  the  credit  of  having  introduced  this 
substance  to  the  profession  as  a  proper  injection  in  cases  of  simple 
hvdrocele.  I  have  adopted  the  suggestion  with  thanks,  but  think  I 
have  improved  the  method.  I  have  applied  it  with  entire  success  to 
hydrocele  simple  (and  in  one  case  complicating  syphilitic  testis),  to 
encysted  hydrocele  of  the  cord,  and  to  spermatocele— all  with  success 
in  each  and  every  instance  save  one,  a  case  of  small  spermatocele.     No 

*  "  Trans.  Med.  Soc.  of  State  of  Pennsylvania,"  1881. 


HYDROCELE— TREATMENT.  ggl 

complication  and  no  serious  reaction  in  any  case  lias  ever  occurred  in 
my  hands.  Pain  is  uniformly  moderate.  No  carbolic-acid  poisoning 
or  any  symptoms  of  it  have  occurred.  I  have  injected  at  the  same  sit- 
ting two  and  a  half  drachms  into  three  separate  cysts,  in  the  cords  of 
an  old  gentleman  past  sixty,  with  entire  success  and  confinement  of 
only  a  few  days.  I  have  operated  on  the  table  at  the  hosjjital  clinic, 
and  had  the  patient  get  up  from  the  table  and  Avalk  down  smiling  to  the 
wards — an  impossibility  if  iodine  had  been  used.  I  have  operated  in  my 
office  in  New  York  and  sent  the  patient  home  in  a  carriage  to  Brooklyn. 
How  many  times  I  have  operated  I  do  not  know,  but  they  count 
by  scores.  I  look  upon  the  injection  as  entirely  innocent  and  harm- 
less, but,  of  course,  I  usually  take  precautions,  and  ask  my  patient  to 
remain  in  bed  one  day.  If,  at  the  end  of  that  time,  he  can  get  up  and 
go  about,  he  may  do  so  ;  if  pain  and  swelling  prevent,  as  they  some- 
times do,  he  must  remain  in  bed  until  motion  is  possible,  using  a  poul- 
tice and  taking  an  anodyne  if  necessary.  I  have  even  aspirated  on 
the  third  day,  in  certain  cases  in  which  the  reaction  has  run  high. 
When  the  patient  goes  about,  he  should  wear  a  suspensory  bandage. 
The  tunica  vaginalis  always  refills  after  the  operation,  and  the  testicle 
is  generally  quite  tense  and  hot  for  a  few  days  after  the  first  twenty- 
four  hours.  Sometimes  it  remains  cool  and  flabby,  but  refills  partly 
with  fluid,  and  the  patient  is  as  nearly  as  possible  devoid  of  pain 
from  one  end  of  the  treatment  to  the  other.  The  reaccumulation  of 
fluid  is  slow  to  absorb,  especially  in  the  flabby  cases  where  there  is  lit- 
tle or  no  inflammatory  reaction,  but  it  always,  in  my  experience,  dis- 
appears totally  within  the  period  of  one  year,  and  the  patient  remains 
perfectly  cured.  I  have  operated  upon  a  child  two  months  old  and 
an  old  man  past  eighty,  always  successfully  thus  far,  and  in  many  in- 
stances I  have  effected  a  cure  after  the  previous  use  of  iodine  at  the 
hands  of  another  had  failed.  To  Dr.  Levis  belongs  great  credit  for 
having  introduced  so  valuable  a  substance. 

My  operative  method  is  very  simple.  The  instruments  are  a  glass 
syringe,  holding  one  hundred  minims,  having  an  ordinary  hypodermic 
point  (rather  large  and  about  two  inches  long)— this,  and  an  aspirator. 
I  fill  the  one-hundred-minim  syringe  with  pure  carbolic  acid  deli- 
quesced with  a  few  drops  of  glycerin.  I  plunge  into  the  hydrocele 
the  needle  of  this  syringe  detached,  and  watch  for  the  oozing  out  of  a 
drop  of  clear  serum  to  announce  the  fact  that  the  tip  of  this  needle  is 
well  within  the  cavity  of  the  tunica  vaginalis.  I  now  insert  the  as- 
pirating-needle  and  rapidly  exhaust  the  hydrocele,  if  possible  to  its 
last  drop,  an  important  measure,  that  the  carbolic  acid  may  not  be 
diluted.  Meantime  the  hypodermic  needle  first  introduced  has  not 
been  disturbed  at  all.  When  all  the  serum  has  been  removed  by  the 
aspirator,  I  screw  upon  the  hypodermic  needle,  first  introduced,  the  one- 
hundred-minim  syringe,  and  rapidly  inject  from  forty  minims  to  one 


3S2  DISEASES   OF   THE   TESTICLE. 

drachm  and  a  half  of  the  pure  acid,  according  to  the  size  of  the  hydro- 
cele, immediately  witiidrawing:  the  needle,  and  leaving  the  acid  within 
the  cavity  of  the  tunica  vaginalis.  This  little  oi)eration  is  clean,  almost 
]iainless,  absolutely  bloodless.  No  anaesthetic  is  required.  The  tes- 
ticle is  maniinihited  a  moment  to  insure  the  diffusion  of  the  acid,  an 
anodyne  is  left  to  be  taken  if  required,  and  next  day,  if  there  is  only 
moderate  pain  with  swelling,  the  patient  gets  up  and  continues  about. 
If  the  reaction  has  been  considerable,  he  remains  in  bed  for  a  few 
days  with  the  testicle  sui)ported.  and  using  such  anodyne  or  local 
soothing  measures  as  his  surgeon  thinks  it  proper  to  order.  Second- 
ary aspiration  gives  relief  if  the  tension  is  great. 

Incision  must  be  employed  where  there  exists  the  least  doubt  as  to 
whether  or  not  tlie  tumor  be  hernia,  where  the  walls  of  the  tumor  are 
very  thick  or  calcareous,  where  its  contents  are  sero-purulent  or  sero- 
sanguinolent,  and  where  injection  has  failed.  Unless  the  position  of  the 
testicle  has  been  positively  made  out  beforehand,  the  sac  should  be 
opened  upon  a  director,  otherwise  a  clean  incision  may  be  made  from 
top  to  bottom  anteriorly.  If  the  walls  of  the  sac  are  very  thick,  and 
especially  if  they  contain  calcareous  plates,  they  should  be  cut  away. 
After  incision,  the  best  treatment  of  the  wound  is  that  suggested  by 
Volkmann,*  namely,  after  antiseptic  irrigation  the  serous  membrane 
or  its  remains,  if  parts  have  been  snipped  away,  are  joined  all  around  by 
many  points  of  fine  suture  to  the  edges  of  the  incision  in  the  scro- 
tum, the  cavity  drained  and  dressed  antiseptically. 

Incision  is  a  harsh  method,  and  entirely  unnecessary  in  simple 
hydrocele,  whatever  its  size.  I  have  cured  a  hydrocele  holding  a  quart 
by  the  carbolic-acid-injection  treatment. 


CONGENITAL   HYDROCELE, 

In  congenital  hydrocele  there  has  been  only  a  partial  obliteration 
of  the  peritoneal  prolongation  at  its  neck,  and,  instead  of  the  usual 
solid,  thin,  fibro-cellular  cord  (Scarpa's  habenula),  we  have  an  open 
canal  making  the  cavity  of  the  tunica  vaginalis  continuous  "with  that 
of  the  peritonaeum.  The  abdominal  serum  gravitates  into  this  cavity, 
and  hydrocele  is  the  result. 

The  diagnosis  is  usually  easy,  but  in  certain  cases  there  is  some 
chance  of  confusion  with  hernia. 

Coiir/cnihxl  Hifdroccle.  Hernial  Tumor. 

1.  Appears  soon  after  birth.  1.  May  appear  at  any  time. 

2.  Tumor  continues  into  inguinal  canal.  2.  Same. 

3.  Receives  impulse  on  coughing.  3.  Same, 

4.  Flatness  on  percussion.  4,  Resonance  on  percussion. 

*  "  Bcrl,  klin.  Wchnschrft.,"  January  17,  1876,  p.  29. 


CONGENITAL   HYDROCELE— TREATMENT.  383 

Congenital  Ihjdrocclc.  Hernial  Tumor . 

6.  Always   reducible   at   an   even  rate,  5.  If   reducible,   goes    back    suddenly, 

more   or  leas  rapidly  according  to  size  of  with  a  {gurgling  sound, 
opening ;  no  jerk. 

6.  Testicle,    entirely    obscured   by   the  6.  Testicle  can  usually  be  made  out  as 
tumor,  reappears  on  the  reduction  of  the  a  distinct  lump. 

latter. 

7.  Feel  soft,  not  doughy.  7.  Doughy    feel — perhaps  gurgling,  on 

manipulation. 

8.  Always  translucent.  8.  Never  translucent. 

A  simple  liydrocele  may  coexist  with  hernia  at  any  time  of  life, 
and  it  is  not  uncommon  for  congenital  hydrocele  to  be  complicated  by 
congenital  hernia  (Fig.  109).     Congenital  hy- 
drocele may  be  found  in  adults,  but  is  rare. 

Treatment  of  Congenital  Hydrocele. — The 
fluid  need  not  be  reduced,  but  a  well-fitting 
truss  must  be  applied.  This  will  usually  ob- 
literate the  neck  of  the  sac,  and  is  Nature's 
method  of  accomplishing  cure.  The  fluid  will 
be  absorbed  in  from  two  to  eight  months  after 
closure  of  the  neck  of  the  sac.  If  not  absorbed, 
the  case,  after  the  neck  is  closed,  may  be  treated 
as  simple  hydrocele.  Complication  with  hernia 
does  not  call  for  any  modification  of  treatment. 
Congenital  hydrocele  should  never  be  injected. 
Desault  and  Dupuytren  did  inject  congenital  hydrocele  with  a  stimu- 
lating fluid,  making,  at  the  same  time,  firm  pressure  at  the  ring. 
This  treatment,  sometimes  successful,  has  also  been  followed  by  fatal 
peritonitis.  If  the  neck  of  the  sac  can  not  be  closed,  the  case  may 
be  left  for  radical  operation  by  the  knife  in  adult  life  by  laying  open 
the  neck  of  the  sac  and  suturing  the  sides  of  the  ring  with  catgut, 
as  for  the  radical  cure  of  hernia. 


Fig.  109  {Madise). 


HYDROCELE    OF   HERNIAL    SAC. 

An  old  hernial  sac  may  become  obliterated  at  its  neck  by  wearing  a 
truss,  or  by  becoming  plugged  up  by  a  portion  of  small  intestine  or  a 
piece  of  omentum.  This  old  sac  may  fill  with  fluid,  and  thus  become 
hydrocele  of  the  hernial  sac. 

The  diagnosis  is  made  mainly  by  a  study  of  the  history  of  the  case. 

Treatment. — Injection  is  not  allowable.  A  careful  incision  is  to 
be  made,  the  fluid  evacuated,  the  intestine  returned,  the  omentum 
cut  off,  the  ring  sewed  up  with  catgut,  the  wound  drained  and  man- 
aged antiseptically,  as  in  the  radical  cure  of  hernia. 


384  DISEASES  OF  THE  TESTICLE. 

SPURIOUS   HYDROCELE    OF   HERNIAL   SAC. 

This  is  a  considorable  aeciimiilatioii  of  lluid  around  an  incarcerated 
hernia. 

Treatment. — Incision  and  operation  for  reduction  of  licrnia. 

The  iluid  in  true  and  in  spurious  hydrocele  of  the  hernial  sac  is 
usually  dark-colored. 

ENCYSTED    HYDROCELE   OP   THE   TESTICLE. 

Simple  cysts,  developed  out  of  the  ]KHliculatcd  or  non-pediculatcd 
hydatids  (so  called),  sometimes  containing  spermatozoa,  are  found 
about  the  head  of  the  testicle.  They  may  be  found  within  simple 
hydrocele,  and  it  is  by  the  bursting  of  one  of  these  cysts  into  the  cav- 
ity of  an  already  distended  tunica  vaginalis  (or  its  puncture  during 
operation)  that  the  contents  of  the  hydrocele  contain  spermatozoa 
(spermatic  hydrocele).  On  this  point  Virchow  and  Gosselin  are  in 
accord. 

Such  cysts  may  be  treated  by  incision  or  injection  with  carbolic  acid. 

SPERMATOCELE. 

Spermatocele  is  a  collection  of  serous  fluid,  containing  spermatic 
elements,  either  in  the  tunica  vaginalis  or  in  a  cyst  situated  near  the 
head  of  the  testicle. 

The  title  has  been  inappropriately  bestowed  upon  another  condi- 
tion, which  may  be  briefly  disposed  of.  When  the  sexual  appetite 
has  been  kindled  and  kept  excited  for  some  time  without  being  grati- 
fied, seminal  fluid,  which  has  been  j^roduced  and  is  collected  in  the 
testicle,  vas  deferens,  and  seminal  vesicles,  will  usually  be  discharged 
in  an  involuntary  emission  at  night,  and  no  inconvenience  Avill  be  felt 
beyond  slight  aching,  and  increase  of  size  of  the  testicle.  Sometimes, 
however,  Nature  fails  to  relieve  herself,  and  then  the  testicle  becomes 
large,  hot,  and  excessively  tender,  the  epididymis  is  distended  and 
knotty,  the  whole  cord  tender  and  tense,  the  scrotum  red,  the  suffering 
very  considerable,  and  the  testicle,  apparently,  about  to  become  acutely 
inflamed.  The  origin  of  the  mischief  can  always  be  ascertained.  A 
cure  follows  a  natural  discharge  of  the  excess  of  semen,  or  may  be 
brought  about  by  rest,  elevation  of  the  testicle,  and  cooling  lotions. 
This  derangement  does  not  deserve  the  name  of  spermatocele.  It 
might  be  called  spermatic  congestion. 

Listen  (1843)  and  Lloyd  (1849)  first  found  spermatozoa  in  the 
fluid  of  hydrocele.  Spermatic  hydrocele  does  not  exist,  except  in  an 
encysted  form,  or  secondary  to  it.  Although  a  tumor  may  resemble 
hydrocele  in  all  respects,  yet  it  may  yield,  on  puncture,  a  milky  fluid 


SPERMATOCELE.  335 

containing  spermatozoa.  In  such  cases  one  of  two  accidents  has  oc- 
curred : 

1.  An  encysted  spermatocele,  jutting  out  within  tlic  tunica  vagi- 
nalis, and  obscured  by  its  fluid,  has  been  punctured  during  tapping  of 
the  latter,  and  thus  allowed  a  mingling  of  spermatic  elements  with 
the  other  contents  of  the  hydrocele. 

3.  The  cystic  spermatocele  has  ruptured  early  in  its  formation, 
discharged  its  contents  into  the  tunica  vaginalis,  and  continued  on 
furnishing  spermatozoa  mixed  with  the  fluid  of  the  hydrocele  (Vir- 
chow,  Gosselin). 

There  exist  normally  upon  the  head  of  the  epididymis  several  little 
prominences,*  solid  and  cystic,  known  as  the  hydatid  of  Morgagni  or 
pediculated  hydatid,  corpus  innominatum  of  Giraldes,  and  non-pedicu- 
lated  hydatids.  They  are  the  remains  of  the  Wolffian  body,  and  of  the 
duct  of  Miiller.  From  one  of  the  non-pediculated  hydatids,  un- 
doubtedly, spermatocele  is  formed,  f 

*  Rosenmiiller,  "  Qusedara  de  ovariis  Embryonum  et  Foetuum  humanorum,"  Lipsise, 
1802.  Kobelt,  "Der  Neben-Eierstock  des  Weibes,"  Heidelberg,  1847.  Miiller's  "Physi- 
ology," by  Baly.  Virchow,  "  Die  krankhaften  Gesehwiilste."  Strieker,  "  Manual  of 
Histology,"  American  edition ;  and  "  Todd's  Cyclopaedia,"  vol.  v,  Supplement,  Art. 
"  Parovarium." 

■)■  The  testicle  is  developed  in  the  foetus,  near  the  Wolffian  body,  but  independent  of 
it.  This  Wolffian  body  consists  of  a  set  of  tubes,  all  of  which  open  into  the  duct  of  the 
Wolffian  body.  The  duct  terminates  in  the  uro-genital  canal.  This  duct  becomes  finally 
the  vas  deferens  in  the  male  (in  the  female  it  atrophies).  Of  the  tubes  forming  the 
Wolffian  body  the  central  ones  unite  by  open  ends  (vasa  recta)  with  the  testicle.  They 
become  the  coni  vasculosi,  and  connect  the  testicle  with  the  canal  of  the  epididymis.  Of 
the  lower  caecal  tubes  of  the  Wolffian  body,  not  connecting  with  the  testicle,  some  atrophy, 
and  others  (one  or  more)  become  developed  into  the  vasa  aberrantia  of  Haller,  while  the 
upper  tubes  atrophy,  or  become  converted  into  non-pediculated  hydatids  (so  called) ;  in 
other  words,  simple  little  cysts  at  the  head  of  the  epididymis.  The  corpus  innominatum 
of  Giraldes,  a  convolution  of  small  tubes,  shut  at  both  ends,  is  another  remnant  of  the 
Wolffian  body.  In  the  female,  all  the  tubes  of  the  Wolffian  body  continue  ctecal.  They 
constitute  the  parovarium  of  Rosenmiiller,  and  furnish  the  little  cysts  so  often  existing 
normally  in  the  broad  ligament,  near  the  outer  border  of  the  ovary. 

Besides  the  duct  of  the  Wolffian  body,  there  is  found  in  the  foetus  another  tube,  be- 
ginning in  a  blind  extremity  running  over  the  tubes  of  the  Wolffian  body,  but  not  con- 
nected with  them  or  with  their  duct,  to  which  it  runs  parallel,  and  emptying  by  a  sepa- 
rate orifice  into  the  uro-genital  canal.  This  is  the  duct  of  Miiller.  In  the  female  it 
forms  the  Fallopian  tube.  Its  extremity  becomes  fimbriated,  and  its  blind  end  atrophies 
or  remains  as  a  small,  pediculated  hydatid.  In  the  male  it  atrophies,  its  blind  extremity 
often  persisting  as  the  hydatid  of  Morgagni  (so  called),  a  pediculated  cyst  at  the  head  of 
the  epididymis.  Its  length  lies  along  the  border  of  the  epididymis,  as  an  atrophied 
thread,  sometimes  showing  hydatidiform  swellings,  while  its  other  extremity  is  repre- 
sented by  the  prostatic  utricle. 

This  insight  into  the  origin  of  the  little  cysts  found  normally  at  the  head  of  the  epi- 
didymis explains  why  we  sometimes  have  developed  there  a  simple  cyst,  and  sometimes  a 
spermatic  cyst.  If  the  hydatid  of  Morgagui  or  one  of  the  hydatidiform  swellings  of  the 
atrophied  duct  of  Miiller  should  become  enlarged  into  a  cyst,  we  should  have  a  simple 
cyst,  for  the  duct  of  Miiller  never  possessed  any  connection  either  with  the  testicle  or  with 
25 


386  DISEASES  OF  THE  TESTICLE. 

It  tends  to  increase  in  size  indctinitely.  It  may  coexist  with  hydro- 
cele, and  be  masked  by  it.  It  may  be  broken  early  by  accident,  and, 
continuinfj  to  secrete,  form  spermatic  hydrocele,  or  it  may  be  punctured 
with  the  trocar  when  a  supposed  sinii)le  hydrocele  is  tapped. 

Symptoms  of  Spermatocele. — When  complicating  simple  hydrocele 
and  jutting  into  the  cavity  of  the  latter,  there  are  no  symptoms  by 
wiiich  si)ermatocele  can  be  distinguished.  Uncomplicated,  it  has 
peculiar  features.  Usually  a  slight  uneasy  sensation  is  experienced 
near  the  head  of  the  epididymis,  not  amounting  to  pain,  often  en- 
tirely unnoticed,  or  at  least  forgotten  by  a  patient  who  may  afterward 
find  the  little  tumor  by  accident.  If  seen  early,  an  uiulofined  sense 
of  thickening  with  extra  resistance  is  distinguishable  by  the  finger,  in 
the  region  of  the  top  of  the  testicle.  This  goes  on  increasing,  usually, 
at  so  slow  a  rate  that  the  patient  soothes  himself  with  the  idea  that  it 
will  become  no  larger.  It  grows,  however,  constantly,  and  may  at- 
tain a  large  size.*  There  is  no  pain,  except  a  slight  dragging  on  the 
cord.  The  cyst  keeps  its  position  at  the  upper  end  of  the  testicle,  and 
becomes  gradually  heart-shaped,  the  testicle  lying  below  at  the  point, 
the  cyst  sometimes  notched  above.  The  walls  are  usually  thin  and 
tense,  so  that  fluctuation  can  not  be  always  distinguished,  but  trans- 
lucency  is  usually  present.  The  fluid  may  be  dark-colored  or  very 
milky,  somewhat  masking  translucency.  The  patient  is  very  apt  to 
become  hypochondriacal,  and  to  imagine  that  his  sexual  appetite  and 
power  are  failing. 

On  tapping  such  a  cyst,  the  fluid  will  usually  be  found  milky  or 
dark-colored,  and  the  microscope  readily  detects  spermatic  elements, 
often  exhibiting  lively  movements,  with  others  more  or  less  decom- 
posed, many  oval  heads  without  the  tails,  blood,  granular  and  fatty 
matter,  and  some  granular  pigment  and  epithelial  cells.  The  diagno- 
sis can  never  be  pronounced  with  absolute  certainty  until  the  micro- 
scope has  detected  spermatic  elements  in  the  fluid. 

Treatment. — After  tapping,  a  spermatocele  will  invariable  refill. 
The  proper  mode  of  treatment  is  by  injection  or  by  incision,  as  in 
hydrocele. 

the  Wolffian  body.  If,  on  the  other  hand,  one  of  the  far  more  numerous  cysts,  the  re- 
mains of  the  upper  blind  tubes  of  the  Wolffian  body,  should  enlarge,  it  is  easy  to  see 
how  the  connection  which  originally  existed  between  this  blind  pouch  and  the  duct  of  the 
Wolffian  body  (now  canal  of  the  epididymis  and  vas  deferns)  might  be  re-established  (or 
never  have  been  closed),  and  seminal  elements  find  their  way  into  the  cyst,  especially  if 
there  were  some  stricture  of  the  canal  of  the  epididymis  or  of  the  vas  deferens.  In  the 
same  way,  if  one  of  the  vasa  aberrantia  should  enlarge,  we  might  readily  have  spermato- 
cele. It  has  been  supposed  that  some  of  the  tubuli  of  the  testis  itself  may  become  en- 
larged into  a  spermatocele,  but  this  has  never  been  demonstrated. 

*  Frost  records  a  case  forty  years  old  yielding  fifty-two  ounces  on  tapping.  "  Lancet," 
December  14,  1878,  p.  483. 


HYDROCELE   OF   THE   CORD.  387 

HYDROCELE    OF    THE    SPERMATIC    CORD. 

Hydrocele  of  the  cord  is  either  diffuse  (infiltrated)  or  encysted. 
The  spermatic  cord  is  enveloped  in  a  loose  layer  of  connective  tissue, 
which  is  continuous  with  the  external  and  internal  connective-tissue 
envelope  (perimysium)  of  the  abdominal  muscles,  starts  at  the  external 
abdominal  ring  and  surrounds  the  whole  cord,  the  epididymis,  and  the 
testicle,  being  firmly  attached  to  the  latter  at  its  lower  end,  and  in- 
separable from  the  reflected  tunica  vaginalis  propria.  The  cremaster 
muscle  is  spread  out  upon  its  external  surface.  This  loose  connective 
tissue  is  described  by  anatomists  as  a  sei^arate  fascia,  and  is  called 
tunica  vaginalis  communis. 

The  meshes  of  this  tunic  sometimes  become  the  seat  of  a  diffuse 
serous  infiltration  (first  described  by  Pott)  constituting  infiltrated 
hydrocele.  Scarpa  has  described  it  as  a  simple  oedema.  Boyers  rec- 
ognizes it  as  a  special  form  of  hydrocele.  Vidal  doubts  its  existence, 
and  Pitha  never  saw  it.  It  is  very  rare.  Curling  believes  it  may  oc- 
cur in  general  anasarca,  and  saw  it  once  complicating  acute  orchitis. 
It  is  mainly  interesting  from  its  liability  to  be  confounded  with  omen- 
tal hernia.  The  symptoms  readily  differentiate  it  from  ordinary 
hydrocele. 

Symptoms. — The  swelling  is  uniform,  round,  and  smooth,  the  in- 
filtration occupying  the  meshes  of  the  connective  tissue ;  toward  the 
base  there  may  be  one  large  cavity.  There  is  no  communication  with 
the  cavity  of  the  tunica  vaginalis  propria.  Enlarged  inguinal  glands, 
or  any  obstruction  to  the  return  of  blood  from  the  testis,  may  act  as 
causes.  The  swelling  ceases,  according  to  Pott,  just  where  the  vessels 
enter  the  testicle,  the  latter  organ  being  isolated  from  the  general 
swellihg.  The  tumor  becomes  more  cylindrical  in  shape  in  the  supine 
position,  but  it  does  not  disappear.  Pressure  makes  it  recede  upward 
slightly,  but  it  returns  in  any  position  of  the  patient.  The  penis 
never  appears  so  much  retracted  as  in  simple  hydrocele  of  equal  size. 

Diagnosis  is  with  omental  hernia.  The  latter,  however,  when  re- 
duced, will  remain  in  the  abdomen  until  the  jDatient  stands  up,  while 
the  hydrocele  will  return  in  any  position  (Pott).  The  surface  is  firmer 
in  epiplocele,  and  the  swelling  larger  above  than  below.  Hydrocele 
is  not  so  entirely  reducible,  and  receives  no  impulse  on  coughing.  In 
irreducible  epiplocele  the  diagnosis  is  difficult,  at  times  impossible. 
Fluctuation  can  be  felt  at  the  bottom,  but  not  at  the  top,  of  diffuse 
hydrocele.  The  enlargement  extends  to  the  ring.  The  shape  is 
rather  pyramidal,  but  can  be  somewhat  altered  by  pressure. 

Treatment. — Palliative  punctures  may  be  made  at  the  bottom  of 
the  swelling.  Large  incisions  are  dangerous.  Pott  lost  a  case  in  this 
way.  When  a  diagnosis  with  omental  hernia  is  impossible,  and  an 
operation  seems  advisable,  an  exploratory  incision  may  be  practiced. 


388  DISEASES   OF  THE   TESTICLE. 

ENCYSTED    HYDROCELE    OF   THE   CORD. 

Cysts  may  form  along  the  cord  in  the  habenula  (remains  of  peri- 
tonea! process  from  the  abdomen  to  the  tunica  vaginalis)  when  its  oc- 
clusion has  been  imperfect  at  certain  points.  Tiie  "  hydrocele  en 
chapclet ''  of  Cloquet  is  so  formed.  Again,  cysts  may  be  developed  at 
any  point  along  the  cord^in  its  connective  tissue,  or  in  the  meshes  of 
the  tunica  vaginalis  communis.  They  vary  in  size  from  a  jiea  to  a 
hen's  Qgg,  or  larger.  They  are  usually  tense,  smooth,  oval,  the  long 
diameter  parallel  to  the  axis  of  the  cord,  translucent,  sometimes  fluc- 
tuating, although  the  tension  of  the  cyst  usually  makes  this  sign  val- 
ueless. Pain  is  absent  or  insignificant.  The  cysts  usually  occur  be- 
tween the  external  abdominal  ring  and  the  testicle,  but  may  also  be 
found  in  the  inguinal  canal.  In  the  latter  situation  it  is  sometimes 
impossible  to  distinguish  such  a  tumor  from  incomplete  inguinal  her- 
nia without  an  exploratory  herniotomy.  When  the  cyst  occupies 
this  position,  whether  in  the  male  on  the  cord,  or  in  the  female  on 
the  round  ligament,  unnecessary  fear  and  anxiety  are  often  excited  in 
regard  to  hernia,  and  a  truss  or  some  other  retaining  bandage  is  usu- 
ally applied.  This  always  gives  rise  to  jDain,  and  considerably  aggra- 
vates the  trouble. 

Treatment. — For  large  encysted  hydrocele  of  the  cord,  injection,  as 
in  simple  hydrocele,  is  the  best  treatment.  Injection  is  inadmissible 
when  the  cysts  are  strung  out  and  communicate,  as  the  result  would 
be  necessarily  imperfect.  For  small  cysts,  whether  single  or  multijile, 
incision  is  the  best  treatment,  care  being  taken  to  avoid  wounding  the 
constituents  of  the  cord.  Incision  is  indispensable  for  cysts  situated 
within  the  inguinal  canal,  or  where  there  is  any  doubt  as  to  hernia. 

HiEiiATOCELE  of  the  cord  is  rare,  but  may  occur  in  the  same  way 
as  haematocele  of  the  tunica  vaginalis,  usually  after  injury.  Indica- 
tions for  treatment  are  the  same. 


CHAPTER  XXIV. 

DISEASES   OF  TUE  TESTICLE. 


Inflammation.— Orchitis.— Causes.— Symptorna.— Pathological  Changes.— Prognosis.— Treatment.— 
Epididymitis.— Frequency  and  Date  of  Appearance  in  Gonorrlia'a.— Causes.— Symptoms. —Ster- 
ility as  a  Result  of  Epididymitis. — Diagnostic  Table  oi  Orchitis  and  Epididymitis.— Treatment 
of  Epididymitis. 

Ikflammatiox  of  the  testicle  may  be  limited  to  the  epididymis 
(epididymitis),  or  may  attack  the  secreting  structure  alone  (orchitis). 
This  has  been  explained  by  the  fact  that  the  arterial  supply  is  differ- 
ent for  the  different  constituents  of  the  testicle.     Sometimes  both 


ORCHITIS— CAUSES.  3S9 

parts  inflame  simultaneously — as  after  injury.  Tlie  secreting  struct- 
ure may  become  secondarily  involved  by  a  simple  inflammation  com- 
mencing in  the  epididymis,  but  the  latter  rarely  suffers  in  connection 
with  primary,  true  orchitis.  The  subserous  connective  tissue  of  the 
tunica  vaginalis,  being  in  direct  continuation  with  the  connective  tis- 
sue of  the  epididymis,  in  the  vast  majority  of  cases  of  epididymitis 
also  becomes  inflamed,  constituting  periorojiitis,  or  acute  hydrocele. 
Periorchitis,  on  the  other  hand,  is  rarer  with  inflammatory  orchitis, 
since  the  dense  structure  of  the  tunica  albuginea  keeps  an  inflammation 
originating  on  one  side  of  it  from  being  rapidly  transmitted  to  the 
other. 

ORCHITIS. 

Causes. — True  orchitis  is  very  uncommon.  As  complicating 
mumps  (so-called  metastatic  orchitis),  no  rational  theory  has  been  ad- 
vanced to  account  for  it.  Observation  abundantly  proves  that  it  oc- 
curs in  at  least  five  per  cent,  as  a  complication  of  mumps  in  young 
adults,  and  the  fact  must  be  accepted  without  explanation.  It  has 
been  noticed,  indeed,  during  the  prevalence  of  an  epidemic  of  mumps, 
that  cases  of  orchitis  occur  spontaneously  in  some  patients  whose 
parotids  escape.*  Orchitis  due  to  mumps  is  most  often  observed  at 
about  the  age  of  puberty.  It  comes  on  near  the  end  of  the  first  week 
of  the  mumps,  and  is  usually  confined  to  a  single  testicle.  The  ejH- 
didymis  is  perhaps  also  involved,  but  may  escape.  The  affection  runs 
a  quick  course  of  about  a  week  or  ten  days,  very  rarely  terminates  in 
suppuration,  usually  subsides  without  leaving  any  impairment  of  the 
organ  behind,  but  is  sometimes  followed  by  atrophy,  f  The  right  tes- 
ticle seems  to  suffer  more  often  than  the  left  (Rilliet).  Isham  J  refers 
to  several  reported  cases  of  alleged  success  in  the  treatment  of  the 
metastatic  orchitis  of  mumps  with  jaborandi.  I  have  used  the  drug  and 
think  well  of  it. 

Orchitis  after  severe  injury  to  the  testis  is  not  uncommon.  It 
tends  to  terminate  in  abscess  or  gangrene,  and  to  be  followed  by 
atrophy,  with  loss  of  function  of  the  organ.  Orchitis  as  a  result  of 
cold  is  possible.  Hanot*  records  a  case  of  spontaneous  orchitis  which 
came  on  during  typhoid  fever  and  was  followed  by  partial  atrophy. 
Terrillon  ||  gives  the  case  of  a  healthy  man  who,  during  an  effort  at 

*  "  Medical  Times  and  Gazette,"  vol.  xix,  p.  512. 

•f  Laveran,  "Medical  Times  and  Gazette,"  July  20,  1878.  Among  four  hundred  and 
thirty-two  cases  of  mumps  in  soldiers,  there  were  one  hundred  and  fifty-six  cases  of 
orchitis — not  metastatic,  as  the  parotid  swelling  did  not  subside  when  the  testicle  swelled. 
Out  of  one  hundred  and  eleven  cases  atrophy  occurred  in  seventy-three.  With  double 
atrophy  virility  is  lost. 

X  "  Amer.  Jour.  Med.  Sci.,"  October,  1878,  p.  369. 

*  Referred  to  in  "  London  Med.  Record,"  December  15,  1878. 

II  "  Ann.  des  Mai.  des  Org.  Genito-urinaires,"  April  1,  1885,  p.  230. 


390  DISEASES  OF  THE  TESTICLE. 

lifting,  felt  a  suddou  pain  in  llic  left  testicle,  which  mounted  into  the 
groin,  remained  there,  inllauicd  and  atrophied  into  a  librous  nodule, 
which,  becoming  neuralgic,  required  ablation,  lie  refers  to  another 
case.* 

Sometimes  orchitis  comes  on  in  children,  and  even  in  adults, 
where  no  sufficient  cause  can  be  assigned.  Excessive  sexual  excite- 
ment has  been  adduced  as  a  cause.  Very  rarely  orchitis  complicates 
variola  or  typhoid  fever.  A  low  grade  of  true  orchitis,  located  in  the 
fibrous  covering  of  the  organ,  is  liable  to  attack  gouty  individuals. 
Orchitis  may  come  on  secondarily  during  ci)ididymitis.  Occasionally, 
especially  in  the  old  or  enfeebled,  true  orchitis  originates  spontane- 
ously in  patients  having  chronic  inflammatory  urethral  or  prostatic 
disease. 

Symptoms. — In  true  orchitis  the  increase  in  size  of  the  testis  gen- 
erally advances  rather  slowly,  and  seldom  becomes  considerable  until 
the  affection  has  lasted  a  length  of  time.  This  is  accounted  for  by 
the  unyielding  nature  of  the  albuginea,  and  the  fact  that  there  is  usu- 
ally no  effusion  into  the  tunica  vaginalis.  The  pain  is  exphiincd  in 
the  same  manner.  It  is  often  excruciating,  and  always  out  of  propor- 
tion to  the  amount  of  swelling.  It  has  been  compared  to  that  of  ne- 
phritic or  hepatic  colic.  No  position  gives  rest,  and  any  handling  of 
the  organ  is  liable  to  induce  syncope.  The  irritated  cremaster  con- 
tracts upon  the  sensitive  testis,  and  draws  it  up  toward  the  groin. 
The  pain  continues  high  for  several  days,  and  then  gradually  becomes 
more  bearable,  or  it  may  suddenly  cease  altogether.  This  last  circum- 
stance is  gratifying  only  to  the  patient.  The  surgeon  learns  it  with 
regret,  for  he  knows  that  it  may  mean  mortification  of  the  organ. 

The  shape  of  the  testicle  is  rarely  altered  in  orchitis  ;  it  is  smoothly, 
regularly  ovoid.  The  epididymis  is  not  distinguishable  from  the  rest 
of  the  tumor.  The  organ  feels  peculiarly  indurated,  the  natural  elas- 
tic feel  having  entirely  disappeared.  The  scrotal  tissues  are  often  red, 
swollen,  cedematous,  inflamed.  There  is  a  strong  tendency  to  suppu- 
ration or  mortification,  the  latter  marked  by  a  sudden  cessation  of 
pain.  The  former  is  often  announced  by  the  occurrence  of  chill. 
After  the  chill  the  testicle  commences  to  enlarge  more  rapidly,  the 
scrotal  tissues  adhere  to  its  surface,  and,  after  a  period  longer  or 
shorter,  according  to  the  depth  at  which  the  matter  forms,  a  soft, 
fluctuating  spot,  surrounded  by  indurated  borders,  indicates  clearly 
the  position  of  the  purulent  collection.  After  the  pus  has  escaped,  all 
the  severity  of  the  symptoms  abates,  unless  a  second  purulent  collec- 
tion exists  in  some  other  part  of  the  gland.  The  flow  of  pus  gradu- 
ally diminishes.  As  it  decreases,  the  swelling  subsides,  and  partial  or 
total  atrophy  of  the  testicle  ensues,  Avith  perhaps  a  fistula  remaining 
open  for  years.     Sometimes  exuberant  granulations  grow  up  out  of 

*  Kocher's  article,  Pitha  and  Billroth,  p.  3C6. 


ORCHITIS— CAUSES,  391 

the  opening,  forming  a  cauliflower  excrescence  (hernia  testis),  wliicli 
may  reach  considerable  size,  and,  growing  as  it  does  out  of  an  en- 
larged, hardened  testicle,  perhaps  at  this  stage  irregularly  lumpy,  and 
containing  some  softer  spots,  while  at  the  same  time  the  glands  in  the 
o-roin  may  become  enlarged,  hardened,  and  tender,  and  the  general 
health  decline — all  this  array  of  symptoms  is  very  liable  to  give  rise  to 
a  suspicion  of  cancer,  a  suspicion  which  the  result  does  not  justify. 

Sometimes  an  abscess  forms  centrally  in  true  orchitis,  and  never 
comes  to  the  surface.  .  In  such  a  case  the  symptoms  run  a  despair- 
ingly slow  course,  but  the  hard  and  tender  organ  gradually  reduces  in 
size,  undergoes  chronic  inflammatory  induration,  Avhilc  the  purulent 
collection  gradually  becomes  solidified,  surrounded  by  a  tough  cap- 
sule ;  perhaps  cretiiSes  and  so  remains  indefinitely,  the  function  of  the 
testicle  being  destroyed,  unless  the  j)urulent  collections  have  been  very 
small.  A  somewhat  similar  state  of  affairs  may  succeed  deep  abscess, 
which  has  discharged  and  remained  fistulous  for  a  considerable  time. 
These  testicles  remain  long  the  seat  of  chronic  pain,  and  are  liable  to 
repeated  outbreaks  of  inflammation. 

Pathological  Changes. — On  section,  it  is  usual  to  find  a  con- 
crete mass  of  more  or  less  solidified  pus  in  some  jjortion  of  the  organ, 
surrounded  by  a  distinct  fibrous  capsule,  while  the  contiguous  struct- 
ure of  the  testicle  is  modified  by  chronic  inflammation,  perhaps  de- 
generated into  a  fibrous  mass.  Concrete  pus  is  distinguishable  from 
cheesy  tubercle  in  that  the  latter  usually  lies  not  encapsulated  in  di- 
rect contact  with  the  seminal  tubules,  which,  though  atrophied  by 
pressure,  are  in  other  respects  sound.  The  yellowish,  gummy  (syph- 
ilitic) tumor  is  distinguishable  from  concrete  jdus  in  not  being  (strict- 
ly) encapsulated,  being  usually  homogeneous,  consistent,  tough  (not 
friable,  like  concrete  pus),  and  being  infiltrated  through  the  convo- 
luted tubes. 

Teemin'Atiois'S.  —  When  orchitis  terminates  in  gangrene,*  after 
adhesion  of  the  scrotum,  the  slough  makes  its  way  through  the  skin, 
and  is  found  to  be  not  black,  or  brown  and  fetid,  like  an  ordinary  slough, 
but  yellowish,  dry,  and  soft.  It  is  a  sort  of  dry  gangrene,  a  necrosis, 
as  Kicord  calls  it,  and  the  slough  may  be  pulled  away  in  long  filaments, 
constituted  by  the  dead  seminal  tubules.  Finally,  two  other  termi- 
nations of  orchitis  are  encountered  : 

1.  Eesolution,  with  a  return  of  the  organ  to  its  full  functional 
power. 

2.  Atrophy,  without  either  necrosis  or  suppuration. 

The  general  symj^toms  in  true  orchitis  are  marked,  often  severe  ; 
slight  chills,  pretty  high  fever,  anorexia,  nausea,  vomiting,  hiccough, 

*  Gangrene  is  very  uncommon.  Consult  an  article  by  Tolkmann,  "  Archiv  f.  klin. 
Chir.,"  xxiv,  3,  p.  399.  Gerster  reports  an  excellent  case,  "  Xew  York  Med.  Jour.,"  June, 
1880,  p.  576. 


392  DISEASES   OF   THE   TESTICLE. 

coustipation,  sleeplessness,  anxiety,  great  nervous  irritation.  The 
general  symptoms  have  been  comjiared  to  those  of  strangulated  hernia, 
and,  indeed,  there  is  strangulation  of  the  testicle  Avithin  its  tight, 
fibrous  sheath. 

Prof/)iosis  is  always  grave  ;  the  most  energetic  treatment  is  called 
for,  to  keep  oil  impending  destruction  of  the  organ. 

Treatment. — Rest  on  the  back  in  bed,  with  the  testicle  supported 
in  a  sling,  is  essential  to  even  moderate  comfort.  The  patient  needs 
no  urging  to  keep  him  lying  down.  If  the  case  is  seen  early,  some  of 
the  large  scrotal  veins  should  be  opened,  and  the  bleeding  encouraged 
by  causing  the  patient  to  sit  in  a  hot  bath,  or  ten  to  fifteen  leeches 
may  be  ajiplicd  in  the  neighborhood  of  the  abdominal  ring.  If  seen 
at  the  very  commencement,  it  might  be  allowable  to  try  the  constant 
application  of  ice-water  in  bladders,  but  this  expedient  has  little  or  no 
influence  over  inflammation  once  under  way  in  the  testicle.  ^Clie  con- 
stipation which  always  exists  should  be  combated.  The  testicle  may 
be  enveloped  in  strong  belladonna-ointment,  or  a  paste  composed  of 
powdered  opium  and  glycerin,  or,  if  the  pain  be  not  too  excruciating, 
in  a  light  tobacco  poultice.  In  short,  the  organ  must  be  narcotized 
and  held  suspended  by  an  appropriate  sling,  so  that  the  venous  blood 
may  be  assisted  in  draining  out  of  it.  The  diet  should  be  low,  non- 
stimulating,  easily  digestible.  The  early  employment  of  these  means 
gives  the  testicle  its  best  chance.  If  in  spite  of  them  the  symptoms 
fail  to  abate,  in  short,  on  the  slightest  suspicion  of  impending  gan- 
grene, or  in  any  case  where  the  symptoms  run  very  high,  it  is  wise  to 
resort  without  delay  to  subcutaneous  section  of  the  tunica  albuginea, 
to  take  off  tension  from  the  strangulated  parts  within.  This  simple 
operation  is  readily  performed  with  a  sharp  tenotomy-knife  introduced 
through  the  skin,  and  then  made  to  cut  the  tense  fibrous  capsule, 
while  the  testicle  is  steady  in  the  other  hand.  The  incisions  should 
be  carried  fairly  through  the  tunica  albuginea,  several  short  cuts  being 
made  at  different  points  on  the  surface  of  the  testicle  (three  to  six), 
not  over  two  or  four  lines  long.  In  this  way  the  tension  being  re- 
lieved, the  pain  will  usually  cease,  and  a  continuance  of  the  means 
above  enumerated  will  probably  lead  to  resolution.  If  abscess  form, 
puncture  should  be  made  on  the  first  appearance  of  fluctuation.  In 
sphacelus,  carbolized  water-dressings  are  advisable. 

Nature  and  time  alone  are  able  in  many  cases  to  close  a  fistitla  of 
the  testicle  left  behind  by  the  opening  of  an  abscess.  All  that  art 
can  do  is  to  make  the  opening  a  depending  one,  slit  up  sinuses,  keep 
the  j)arts  clean,  apply  some  stimulating  lotion  or  injection  to  the 
sinus,  and  build  up  and  maintain  the  patient's  general  health. 

In  benign  fungus  (hernia  testis),  besides  the  above  means  aj^plied 
to  the  opening  from  which  it  grows,  the  mass  itself  may  be  cauterized, 
cut  or  tied  off,  subjected  to  pressure  by  adhesive  straps,  or,  preferably, 


EPIDIDYMITIS.  393 

after  other  diseased  conditions  have  been  subdued,  the  edges  of  the 
wound  may  be  incised,  freshened,  and  united  by  suture  after  the 
fungus  has  been  replaced  (Syme).  Fungus  should  never  be  pulled 
upon,  for  fear  of  drawing  out  the  entire  contents  of  the  testicle. 

In  severe,  long-standing  cases,  where  a  testicle  is  the  seat  of 
chronic  induration  full  of  fistula?,  or  with  large,  obstinate  fungus,  cas- 
tration is  advisable,  sometimes  necessary,  in  order  to  remove  from  the 
patient  a  source  of  physical  irritation,  and  to  save  him  from  serious 
injury  to  the  general  health. 

EPIDIDYMITIS. 

Epididymitis  is  the  most  common  of  all  the  diseases  of  the  testicle. 
It  occurs  at  all  ages,  most  frequently  during  early  adult  life  and  mid- 
dle age,  since  its  chief  cause — urethral  inflammation  or  irritation — 
most  commonly  exists  during  these  periods  of  life.  It  has  an  acute 
form,  but  is  very  prone  to  run  into  the  chronic  state,  and  may  be  sub- 
acute from  the  first.  It  habitually  terminates  in  resolution,  rarely  in 
abscess.  One  attack  predisposes  to  another.  It  is  often  double,  but 
the  two  testicles  are  very  rarely  simultaneously  involved  ;  one  usually 
precedes  the  other  by  a  number  of  days  or  weeks,  after  which  the 
disease  sometimes  returns  to  the  testicle  first  invaded,  chiefly  in  badly- 
managed  cases.  Fournier  *  has  never  seen  double  simultaneous  epididy- 
mitis.   It  is  uncommon  but  does  occur.    I  have  encountered  it  twice. 

Although  the  epididymis  bears  the  brunt  of  the  disease,  it  rarely 
suffers  alone,  except  in  very  mild  or  chronic  cases.  In  all  acute  attacks 
the  tunica  vaginalis  is  more  or  less  involved,  giving  rise  to  acute  hydro- 
cele, and  sometimes  the  secreting  structure  of  the  testis  takes  fire  as 
well.  One  particularly  interesting  feature  of  the  disease  is  the  fact, 
mainly  brought  out  of  late  years  by  Oosseliu,  that  the  chronic  indura- 
tion so  often  left  behind  in  the  epididymis  by  inflammation  sometimes 
blocks  up  the  tubes  sufficiently  to  prevent  the  passage  of  the  spermatic 
elements,  thus  entailing  temporary  and  sometimes  permanent  sterility, 
without  an  accompanying  loss  of  sexual  power. 

Feequeintct  of  Epididymitis  and  Date  of  its  Appeaeaxce  lif 
Go]sroEEH(EA. — Fournier  states  that  epididymitis  occurs  about  once  for 
every  eight  or  nine  cases  of  gonorrhoea ;  Sigmuud  puts  it  at  six  or 
eight  per  cent.  The  left  testicle  suffers  more  often  than  the  right.  In 
some  individuals  there  seems  to  be  a  predisposition,  so  that  every 
attack  of  gonorrhoea,  notwithstanding  the  utmost  care,  is  invariably 
attended  by  swelled  testicles  ;  while  others,  regardless  of  all  hygienic 
precautions,  go  around  with  a  raging  gonorrhoea,  employing  perhaps 
no  treatment,  continuing  sexual  intercourse  and  the  abuse  of  alcohol, 
not  even  supporting  the  testicle  with  a  suspender,  and  yet  they  escape. 

*  Art.  " BlcnuoiThagie,"  "Diet,  de  Med.  et  de  Chir.  prat.,"  p.  211. 


394 


DISEASES  OF  THE  TESTICLE. 


Foamier  saw  it  develop,  on  the  other  hand,  in  a  gonorrhoeal  patient 
with  typhoid  fever,  who  had  not  ])nt  his  foot  to  the  ground  for  six 
weeks.  Here  the  generally  shattered  condition  of  the  patient,  brought 
about  by  typhoid  fever,  probably  acted  as  a  ]iredisposing  cause.  It 
may,  however,  be  stated  dogmatically,  that  while  a  gonorrhoea  of  itself 
will  sometimes,  in  spite  of  all  precautions,  occasion  swelled  testicle, 
yet  this  complication  is  not  apt  to  ensue  if  the  patient  wear  a  suspen- 
sory bandage,  abstain  from  violent  or  jolting  exercise  (horseback,  danc- 
ing), and  avoid  bodily  fatigue  and  efforts  at  lifting.  Above  all,  sexual 
excitement  or  indulgence,  and  the  use  of  alcohol  in  any  shape,  must 
be  interdicted.  The  passage  of  instruments  through  a  canal  subject 
at  the  time  to  gonorrhoea  is  a  sufficient  cause  for  epididymitis.  The 
power  of  the  suppressive  treatment  of  gonorrhoea  by  strong  injections 
early  in  the  disease,  although  somewhat  active,  has  been  overrated. 
It  should,  however,  be  borne  in  mind.  Balsams  and  terebinthinates 
internally  can  not  give  rise  to  the  affection. 

The  remarks  already  made  concerning  the  liability  to  epididymitis 
in  gonorrha?a  apply  with  about  equal  force  to  cases  of  stricture.  Some 
patients  suffer  from  the  worst  of  the  inflammatory  sequences  of  strict- 
ure, but  the  testis  escapes  ;  while  in  other  cases,  perhaps  of  mild  type, 
one  or  the  other  epididymis  will  be  constantly  falling  into  trouble  on 
the  slightest  provocation,  until  the  normal  condition  of  the  urethra 
has  been  restored.  The  treatment  of  stricture  by  instrument  may 
itself  originate  epididymitis. 

As  to  the  date  of  occurrence  of  gonorrhoeal  epididymitis,  Fournier 
has  a  personal  tabulation  of  232  cases,  of  which  there  occurred — 


In  the  first       week. 

"  second  " 

"  third  " 

"  fourth  " 

"  fifth 

"  sixth  " 

"  seventh  " 

"  eighth  " 


0 

Mali 

ing  in 

the  first      mo 
second 
third 
fourth 
fifth 
sixth 
seventh 
eighth 
ninth 

nth 

86 

22 
34 
SO 

11 

...    .    18 

22 

6 

oq 

(1 

6 

19 

It 

4 

9 

a 

3 

01 

11 

3 

11 

4 

Later  10,  of  which  in  the  seventh  year  1  ;  most  of  the  latter  cases  de- 
pend evidently  upon  stricture. 

De  Castelnau's  exhibit,*  derived  from  the  statistics  of  four  surgeons, 
shows  a  total  of  239  cases,  of  which  there  occurred — 


In  the  first      week. 
"      second     " 
"      third        " 


In  the  fourth  week 39 

"      fifth         "     54 

"       sixth        "     and  later 12 


Unfortunately,  this  "and  later"  is  deceptive,  since  it  includes  all 
cases  of  epididymitis  due  to  stricture. 

*  Quoted  by  Bumstead. 


EPIDIDYMITIS— CAUSES.  395 

It  is  probable  that,  as  a  rule,  the  time  for  tlic  occurrence  of  epididy- 
mitis in  gonorrha3a  has  been  set  down  a  little  too  late.  In  every-day 
practice  it  is  perhaps  nearly  as  common  to  find  tliis  complication  before 
as  after  the  sixth  week.  In  a  general  way  it  may  be  laid  down  that 
epididymitis  is  to  be  looked  for  mainly  from  the^third  to  the  eighth 
week  of  gonorrhoea.  A  number  of  cases  ai'c  on  record  in  which  it 
is  alleged  that  epididymitis  has  preceded  the  gonorrhocal  outbreak 
(Pourneaux-Jordan,  Sturgis,  Stansbury,  Castelnau,  Vidal).  In  my 
opinion  these  are  not  true  cases  of  gonorrhoea,  but  instances  of  bastard 
gonorrhoea,  in  which  a  deep  urethra  already  damaged  is  kindled  by 
sexual  exercise  into  acute  irritation,  which  promptly  shows  itself  by 
producing  swelled  testicle,  and  only  later  manifests  itself  as  a  discharge 
at  the  urethral  orifice. 

Causes. — Nearly  all  the  causes  enumerated  as  capable  of  producing 
orchitis  may  also  exceptionally  give  rise  to  epididymitis  :  traumatic 
violence,  cold.  Prolonged,  sexual  excitement  may  cause  it,  and  gout, 
but  urethral  infiammation  or  irritation  is  by  far  the  most  active  cause. 
The  most  common  form  of  this  irritation  is  gonorrhoea,  or  urethritis, 
then  stricture,  finally  any  prostatic  or  urethral  irritation,  the  passage 
of  instruments,  especially  through  a  urethra  already  affected  by  mild 
chronic  inflammation  or  stricture,  but  occasionally  where  no  appreci- 
able disease  exists,  the  use  of  the  lithotrite,  cutting  operations  for 
stone,  retention  of  a  small  calculus  or  stone  fragment  in  the  prostatic 
urethra ;  in  short,  any  inflammatory  affection  of  the  prostatic  sinus 
around  the  orifices  of  the  ejaculatory  ducts. 

It  is  probable,  with  all  this  last  series  of  causes,  that  the  mechanism 
of  the  cause  is  identical ;  namely,  that  the  prostatic  sinus  in  the  neigh- 
borhood of  the  orifices  of  the  ejaculatory  ducts  first  becomes  inflamed, 
if  only  slightly,  and  that  the  inflammation,  starting  there,  travels  rapidly 
down  the  continuous  mucous  membrane  of  the  vas  deferens  to  the 
epididymis,  where  it  locates  itself.  That  this  is  sometimes  the  method 
of  propagation  is  demonstrable  by  the  course  of  the  symptoms,  and  by 
the  traces  of  inflammation  occasionally  found  in  the  vas  deferens  after 
death  ;  but  in  the  vast  majority  of  instances  the  inflammation,  pass- 
ing rapidly  through  the  vas  deferens,  announces  its  course  by  no 
symptoms,  and  leaves  no  vestige  of  its  presence  behind.  This  has 
induced  Brown-Sequard  to  deny  that  epididymitis  is  a  transmitted 
inflammation,  and  to  claim  that  it  is  a  reflected  irritation.  He  draws 
a  comparison  between  the  passing  of  a  sound  through  a  seemingly 
healthy  urethra,  or  an  inflammation  existing  in  the  canal,  and  the 
subsequent  epididymal  swelling,  and  ulceration  of  the  small  intestine 
after  extensive  peripheral  burns.  Pournier  has  cautiously  emitted 
the  theory  that  epididymitis  may  be  a  specific  gonorrho?al  affection  of 
the  rheumatic  type,  like  the  gonorrhoeal  (rheumatic)  affections  of  the 
eye  ;  still  this  would  fail  to  account  for  epididymitis  from  the  passage 


396  DISEASES  OF  THE  TESTICLE. 

of  an  instrument  or  the  lodgment  of  a  stone  fragment.  To  sum  up 
briefly,  the  theory  most  plausible  and  best  borne  out  by  observed  facts 
is,  that  epididymitis  from  urethral  inflammation  or  irritation  is  a 
direct  but  sudden  transmission  of  inflammation  over  a  continuous 
membrane,- from  the  orifice  of  an  ejaculatory  duct  to  the  epididymis. 
This  is  further  supported  by  the  following  facts  :  E})idi(lymitis  from 
gonorrho?a  rarely  comes  on  early  in  tiie  disease,  unless  instruments  or 
irritating  injections  have  been  used,  but  occurs  toward  the  end  of  the 
causing  malady,  just  when  the  latter  occupies  the  lower  end  of  the 
urethra.  The  mucous  meml)rane  behind  a  tight  stricture  is  always 
more  or  less  inflamed,  and  this  inflammation  is  liable  at  times,  in  bad 
cases,  to  run  backward  and  affect  the  neck  of  the  bladder.  Under 
these  circumstances,  mild,  continuous  forms  of  epididymitis  are  not 
uncommon.  The  deeper  down  the  urethra  the  stricture  lies,  the  more 
apt  is  epididymitis  to  complicate  it.  Instrumental  interference,  or  the 
retention  of  a  stone  fragment  in  the  forward  parts  of  the  urethra,  is 
very  rarely  attended  by  epididymitis,  while  this  complication  is  not 
uncommon  when  the  same  irritation  is  applied  to  the  prostatic  portion 
of  the  canal. 

Symptoms. — Epididymitis  may  come  on  in  an  acute  or  a  subacute 
form,  the  latter  where  the  epididymis  has  previously  suffered  from 
a  similar  attack.  First  attacks,  like  first  attacks  of  gonorrooha,  are 
usually  the  most  severe.  Epididymitis  is  ushered  in  by  premonitory 
symptoms  which  j)recede  the  swelling  by  some  hours.  Gonorrhoeal  or 
gleety  discharge  is  usually  not  visibly  modified  until  after  the  testicle 
begins  to  swell.  Then  it  becomes  lessened,  perhajos  stops,  to  return 
again  as  soon  as  the  inflammation  of  the  epididymis  is  fairly  on  the 
decline. 

A  vague  uneasiness  is  felt  in  the  testicle,  and  along  the  cord  up 
into  the  back,  as  if  the  cord  were  being  pulled  upon.  Attentive  pa- 
tients will  frequently  aver  that  the  pain  was  noticeable  in  the  groin 
for  some  hours  before  any  uneasiness  was  experienced  in  the  testicle. 
This  forerunning  inguinal  pain  is  rarely  absent  where  the  epididymitis 
is  of  urethral  origin — except  in  hospital  patients,  who  are  unintelli- 
gent observers.  There  is  usually  only  a  slight  painful  tension  in  the 
groin,  but  sometimes  it  is  very  severe,  extending  around  to  the  lum- 
bar region,  and  up  the  back.  Sometimes  there  is  a  sense  of  weight  in 
the  perinaeum,  frequent  desire  to  urinate,  with  perhaps  pain  and  diffi- 
culty in  the  act.  Occasionally  a  chill,  with  febrile  action,  will  usher 
in  the  affection,  but  these  symptoms  are  far  more  constant  with 
orchitis. 

Whether  any  of  the  foregoing  symptoms  have  attracted  attention 
or  not,  within  a  few  hours  decided  pain  is  felt  in  the  testicle,  attended 
by  a  rapid  increase  in  size.  The  amount  of  pain  and  swelling  varies 
in  different  cases.     In  the  subacute  form  of  patients  Avith  stricture. 


EPIDIDYMITIS— SYMPTOMS.  397 

the  swelling  is  moderate,  comes  on  rather  slowly,  palpation  at  once 
distinguishes  the  heat,  sensibility,  and  hardness  of  the  epididymis, 
and  that  the  testicle  itself  is  less  affected.  Periorchitis  is  absent,  or 
not  marked.  There  is  but  little,  if  any,  fluid  in  the  tunica  vaginalis, 
or  it  may  be  felt  loosely  in  the  sac,  not  causing  any  considerable  dis- 
tention. With  such  mild  cases  there  are  no  general  constitutional 
symptoms,  and  the  pain  is  not  excruciating.  It  is  aggravated  by  the 
erect  posture,  but  wholly  disappears  after  the  patient  has  been  on  his 
back,  with  the  testicle  elevated,  for  a  few  moments.  The  scrotal 
structures  escape  implication. 

But  the  picture  changes  vastly  for  the  onset  of  an  acute  attack. 
The  swelling  commences  promptly,  and  increases  with  rapidity.  First 
it  is  localized  posteriorly,  but  soon  the  subserous  connective  tissue  of 
the  tunica  vaginalis  carries  the  inflammation  to  the  latter  structure, 
which  rapidly  inflames,  pouring  out  a  plastic  material  upon  its  sur- 
face, and  a  sero-sanguinolent  fluid  into  its  cavity,  which  becomes  rap- 
idly tense  and  distended,  greatly  adding  to  the  pain.  The  secreting 
structure  of  the  testicle  is  often  distended  fully  with  blood,  but  is  not 
the  seat  of  any  pathological  changes.  The  scrotal  tissues  inflame  and 
become  oedematous,  large  veins  sometimes  appearing  on  its  surface. 
Yet,  even  under  all  these  disadvantageous  surroundings,  with  an  oedem- 
atous scrotum  and  a  tensely-filled  tunica  vaginalis,  careful  examina- 
tion will  rarely  fail  to  localize  all  the  hardness  and  most  of  the  pain  in 
the  epididymis.  The  inflamed  mass  rapidly  reaches  the  size  of  the  fist, 
but  its  shape  is  not  so  evenly  oval  as  in  orchitis.  The  cord  becomes 
swollen,  and  painful  on  pressure.  Occasionally  so  much  inflammatory 
swelling  exists  here  that  the  cord  becomes  partly  strangulated  in  the 
inguinal  canal,  since  it  is  impossible  for  it  to  swell  much  there,  sur- 
rounded as  it  is  by  firm  fibrous  structures.  This  gives  rise  to  all  the 
well-known  symptoms  of  inflammatory  strangulation — excessive  local 
pain,  great  prostration,  anxiety,  vomiting,  perhaps  hiccough. 

Pain  in  acute  epididymitis  is  great,  increasing  from  the  first  pro- 
portionally with  the  rapidity  of  growth  of  the  swelling.  The  pain, 
however,  is  not  so  severe  as  in  true  orchitis.  It  is  of  the  sickening 
variety,  making  patients  feel  faint.  Locomotion  is  almost  (sometimes 
quite)  impossible,  the  motions  of  the  patient  are  very  deliberate  as  he 
changes  his  position,  and,  if  necessitated  to  stand,  he  carefully  sup- 
ports and  shields  his  swollen  scrotum  with  his  hand.  Eest  on  the 
back,  with  the  testicle  raised,  while  it  modifies,  does  not  allay  the 
pain,  but  in  this  position  the  torture  is  more  bearable.  If  strangula- 
tion of  the  cord  at  the  ring  occurs,  the  pain  is  greatly  intensified,  re- 
sembling that  described  for  acute  inflammatory  true  orchitis,  being, 
in  fact,  dependent  on  the  same  cause — inflamed  tissues  strangulated 
within  unyielding  fibrous  coverings.  If  some  inflammation  of  the 
body  of  the  testis  exist,  the  pain  will  be  proportionally  heightened. 


398  DISEASES  OF  THE  TESTICLE. 

As  tlie  disease  advances,  pain  increases  in  intensity  for  several 
days  (three  to  six),  remains  stationary  for  several  days  after  the  organ 
has  reached  its  full  size,  and  finally  begins  to  decrease,  and,  even  in 
desperate  cases,  by  the  end  of  the  second  week  has  usually  disap- 
peared, or  become  reduced  to  the  slight  dragging  uneasiness  which 
constitutes  the  only  pain  of  mild  cases.  This  relief  from  pain  is  often 
experienced  while  the  organ  is  yet  large,  the  epididymis  thickened, 
the  scrotum  oedcmatous;  and  some  fluid  still  left  in  the  tunica  vagi- 
nalis. For  several  days  after  the  pain  has  ceased,  a  few  moments  in 
the  erect  posture,  with  the  testicle  hanging,  will  recall  it.  The 
form  and  size  of  the  swelling  vary  greatly.  In  the  mildest  cases 
the  tail  of  the  epididymis  alone  suffers.  All  the  inflammation  local- 
izes itself  there,  forming  a  hard,  sensitive  lump,  giving  a  little  uneasi- 
ness unless  supported,  everything  else  being  normal.  The  head,  to- 
gether with  the  tail  of  the  epididymis,  may  suffer,  nothing  else  be- 
ing involved,  or  tlic  whole  of  the  epididymis,  while  the  gland  proper 
may  be  felt  normal  in  every  respect  in  front  of  the  inflamed  mass. 
The  vas  deferens  may  be  also  involved  in  mild  chronic  cases,  as  in 
the  tuberculoid  varieties.  It  may,  however,  in  any  inflammation  of 
the  epididymis,  be  increased  in  size  (perhaps  greatly  so),  and  painful 
on  pressure.  In  very  acute  attacks  the  whole  cord  is  sensitive  and 
hypercTinic.  The  seminal  vesicles  are  also  occasionally  inflamed  at  the 
same  time.  Very  rarely  peritonitis  has  been  seen  to  come  on,  provoked 
by  the  last-named  complications  (Hunter,  Velpeau,  Eicord). 

If  the  disease  be  at  all  acute,  the  tunica  vaginalis  is  sure  to  be  in- 
volved, the  degree  of  its  inflammation  usually,  but  not  invariably,  co- 
inciding with  the  intensity  of  the  epididymitis.  This  periorchitis 
varies  greatly.  Fluid  may  be  rapidly  poured  out,  filling  the  sac  to  its 
utmost,  giving  rise  to  a  tense  swelling  of  considerable  size,  in  which 
case  it  becomes  impossible  to  distinguish  the  constituent  parts  of  the 
testicle.  This  form  is  often  attended  by  excruciating  pain,  relieved, 
as  if  by  magic,  by  puncture  of  the  tunica  vaginalis.  Again,  but  little 
fluid  may  be  effused.  This,  lying  loosely  in  the  sac,  fluctuates  freely, 
and  does  not  in  the  least  obscure  the  fact  that  the  main  disease  is  in 
the  epididymis.  The  fluid  may  be  absorbed  speedily,  allowing  the 
plastic  material  effused  with  it  to  glue  together  the  two  surfaces  of 
the  vaginal  tunic,  or  perhaps  only  to  form  numerous  bridled  adhe- 
sions. Some  fluid  may  remain  throughout — the  nucleus  of  future 
hydrocele.  In  acute  cases  the  scrotum  may  be  so  inflamed  and  oedema- 
tous  as  to  give  a  very  exaggerated  idea  of  the  size  of  the  tumor. 

Tlie  constitutional  symptoms,  fever,  loss  of  appetite,  etc.,  are  mild 
with  epididymitis,  do  not  occur  at  all  in  chronic  and  subacute  cases, 
and  in  acute  cases,  like  the  pain,  vary  with  the  intensity  of  the  inflam- 
mation. What  fever  there  is  disappears  before  the  pain,  and  long  be- 
fore the  swelling. 


EPIDIDYMITIS— SYMPTOMS.  399 

Epididymitis  may  be  said  to  have  a  natural  limit  for  its  acute  symp- 
toms of  about  two  weeks,  but  relapses  are  very  common,  and  careless- 
ness may  prolong  the  trouble  to  as  many  months.  Hardness  of  tlio 
epididymis  may  remain  behind  for  months,  or  even  years  ;  such  indura- 
tions retain  their  sensitiveness  on  pressure  for  a  long  time.  Relapses 
are  always  milder  than  first  attacks.  If  the  other  testicle  inflame  be- 
fore the  first  is  well,  the  latter  runs  through  its  course  more  quickly. 

The  gradual  disaj)pearauce  of  the  hardness  from  the  epididymis 
may  extend  over  many  years,  and  in  some  cases  is  never  accomplished 
entirely.  The  body  first  attains  its  natural  feel,  then  the  head,  and, 
last  of  all,  the  tail.  The  absorption  starts  rapidly,  but  progresses 
more  and  more  slowly,  until  in  some  cases  it  seems  to  rest  stationary. 
In  such  cases  the  little  hard  lump  at  the  bottom  of  the  epididymis 
occasions  the  patient  no  uneasiness,  is  not  sensitive  to  pressure,  and  is 
ignored.  Suppuration  is  very  rare  in  true  epididymitis,  not  tuberculoid 
in  character  ;  atrophy  never  occurs  unless  the  substance  of  the  testi- 
cle has  been  involved. 

Sterility. — In  connection  with  the  sterility  often  following  double 
epididymitis,  the  pathological  changes  seen  on  section  are  instructive, 
and  fully  explanatory.  In  the  early  stages,  hyperemia,  plastic,  se- 
rous, and  sanguinolent  effusions  occur.  These  plastic  deposits  take 
place  in  the  cavity  of  the  epididymal  tubules  as  well  as  around  them, 
gluing  them  firmly  together,  so  that  after  a  certain  time,  especially  in 
the  tail  of  the  epididymis,  nothmg  can  be  distinguished  on  section 
but  a  homogeneous  mass,  in  which  the  eye  seeks  in  vain  to  trace  out 
the  convolutions  of  the  epididymis  or  the  course  of  its  canal.  In  the 
case  of  a  patient  of  Velpeau,*  an  examination  of  the  specimen  by 
Eobin  disclosed  the  fact  that  the  hard  lump  occupying  the  epididymis 
was  homogeneous,  resembling  cheesy  tubercle  on  section.  The  con- 
voluted tubes  inclosed  in  this  mass  were  dilated  to  several  times  their 
ordinary  size,  but  filled  with  the  products  of  inflammation — jDus-cor- 
puscles,  fatty  debris,  granulation  bodies — all  of  this  being  within  and 
none  without  the  tube,  looking  as  if  all  the  inflammatory  action  had 
expended  itself  in  producing  secretion  in  and  upon  the  free  mucous 
surface,  not  extensively  involving  the  peritubular  tissue.  Gosselin  f 
found  in  his  interesting  dissections  that  the  canal  in  the  lower  part  of 
the  epididymis  was  often  impermeable,  the  tubes  beyond  the  obstruc- 
tion being  sometimes  dilated,  sometimes  normal 

Testicles  in  these  cases  of  obstruction  do  not  atrophy,  nor  do  the 
seminal  vesicles  of  the  same  side  undergo  any  change.  For  purposes 
of  prognosis  it  is  well  to  recall  the  anatomical  fact  that  the  head  of 
the  epididymis  is  formed  of  many  tubes  (coni  vasculosi),  all  going  to 
unite  with  and  pour  their  secretion  into  the  canal  of  the  epididymis. 

*  Reported  in  the  "  Gazette  des  Hopitaux,"  December,  1854. 
f  "  Archives  Generales,"  Fourth  Series,  xiv,  xv. 


400  DISE.iSES  OF  THE  TESTICLE. 

Hence  chronic  induration  hero  may  have  allowed  one  or  more  tubes 
to  escape,  and  sterility  is  not  so  inevitable.  The  tail  of  the  epididy- 
mis, on  the  other  hand,  as  Gosselin  sagely  pointed  out,  is  composed  of 
the  convolutions  of  one  tube.  This  tail  of  the  epididymis,  too,  is  just 
the  spot  Avl'ioro  the  chronic  induration  left  behind  by  epididymitis  is 
apt  to  become  localized.  The  tube  obliterated  here  cuts  ofT  communi- 
cation with  the  testicle,  and,  if  both  sides  arc  affected,  no  spermato- 
zoon can  reach  the  urethra. 

Yet  it  is  well  to  know  that  even  in  these  cases  affairs  arc  not  always 
desperate.  The  patient  is  by  no  means  impotent,  his  sexual  power  and 
appetite  are  unimpaired.  He  ejaculates  semen  resembling  the  healthy 
fluid  in  quantity,  smell,  and  color,  only  it  contains  no  siiermatozoa,  and 
consequently  he  is  sterile.  The  same  holds  good  usually  of  a  monor- 
chid  who  has  epididymitis  on  the  sound  side,  for  the  retained  tes- 
ticle seldom  furnishes  spermatozoa.  This  sterility  is  in  my  opinion 
generally  permanent,  and  I  have  studied  a  great  number  of  cases  at 
all  ages  after  tlie  disease,  and  failed  to  accomplish  cure  by  a  great  va- 
riety of  treatment.  Yet  I  can  not  assert  that  it  does  not  sometimes 
get  well.  Certain  it  is  that  some  patients  who  allege  that  they  have 
had  double  epididymitis  in  their  youth,  are  yet  perfectly  fertile. 

A  curious  fact  in  connection  with  tiiis  subject  (showing  the  bound- 
less kindness  of  Nature  in  doing  everything  to  preserve  the  genital 
functions  uninjured)  is,  that  the  testicle  does  not  atrophy,  no  matter 
how  long  its  duct  may  be  occluded,  and,  if  the  latter  finally  become 
pervious,  the  testicle  is  ready  for  use.  Animals  have  been  experi- 
mented upon  by  having  their  vasa  deferentia  cut,  but  the  testicle  does 
not  atrophy.  Healthy  spermatozoa  are  found  in  it  months  afterward 
(Curling).  Another  curious  fact  is,  that  in  man  sexual  intercourse 
may  be  practiced  without  (as  might  have  been  expected)  causing  pain- 
ful, or  inducing  any,  swelling  of  the  testicle  or  upper  portions  of  the 
epididymis  from  the  accumulation  of  spermatic  elements. 

In  the  vast  majority  of  cases  time  alone  will  remove  the  indurations, 
and  with  them  the  sterility  ;  and  even  this  can  not  be  counted  on. 

Diagnosis. — The  following  table  may  be  of  service-as  bringing  into 
contrast  the  most  marked  diagnostic  differences  between  true  orchitis 
and  epididymitis.  Of  course,  when  orchitis  comiDlicates  epididymitis 
the  symptoms  will  be  mixed. 

Orchitis.  Epididymitis. 

1.  Comparatively  rare.  1.  A  very  common  affection. 

2.  Causes  usually,  injury,  mumps,  gout,  2.  Cause  almost  invariably  urethral  in- 
cold,  etc.  flammation  or  irritation. 

3.  Pain  usually  excruciating,  and  not  3.  Pain  usually  bearable  except  with 
relieved  by  position,  while  enlargement  is  extreme  enlargement,  always  modified  by 
still  moderate.  position,  except  in  cases  of  strangulations 

of  the  cord. 


EPIDIDYMITIS— TREATMENT. 


401 


Orchitis. 
'      4.  Shape  of  tumor  oval. 

5.  Epididymis  not  distinguishable  from 
the  rest  of  the  tumor. 


6.  Testicle  of  peculiar  hardness,  very 
sensitive. 


I.  Rarely  any  fluid  in  tunica  vaginalis. 

8.  Constitutional  symptoms  usually 
present. 

9.  Termination  in  resolution,  abscess, 
gangrene,  chronic  induration,  or  atrophy. 

10.  Never  followed  by  sterility  except 
as  result  of  destruction  of  tissue,  and  then, 
if  both  sides  have  suffered,  by  impotence 
as  well. 

II,  Course  often  slow. 


Epididymitis. 

4.  Shape  oval,  roundiah,  oblong,  often 
irregular — especially  from  scrotal  (f;doma. 

5.  Epididymis  distinguishable  from  the 
rest  of  the  tumor,  enlarged,  indurated,  and 
particularly  tender;  testicle  often  percep- 
tible, of  natural  feel  in  front  of  it.  These 
symptoms,  perhaps  obscure  for  a  few  days, 
at  the  height  of  the  affection,  always  hold 
good  during  the  period  of  decline. 

6.  Testicle  often  normal  in  front  of 
epididymis ;  perhaps  hard  from  inflamma- 
tion of  its  tunics,  but  not  as  sensitive  as  in 
orchitis. 

V.  Always  fluid  in  tunica  vaginalis  in 
acute  cases. 

8.  Constitutional  symptoms  absent  or 
unimportant. 

9.  Termination  habitually  in  resolution, 
leaving  slight  chronic  thickening  of  tail  of 
the  epididymis  behind. 

10.  Often  followed  by  temporary,  some- 
times indefinite,  sterility  if  both  sides  have 
suffered :  never  by  impotence. 

11.  Course  generally  rapid. 


Treatment. — The  prophylactic  treatment  of  epididymitis  is  the  use 
of  a  suspensory  bandage  during  the  existence  of  urethral  disease,  to- 
gether with  a  strict  observance  of  the  hygiene  of  the  urethra  (p.  43). 
When,  late  in  gonorrhoea,  or  during  treatment  of  stricture,  complaint 
is  made  of  a  dragging,  uneasy  sensation  in  the  groin  or  testicle,  the 
patient  should  be  immediately  placed  upon  his  back,  with  the  testicle 
elevated,  and  the  threatened  attack  may  thus  be  often  averted. 

In  mild  cases,  where  rest  on  the  back  with  elevation  of  the  testicle 
is  sufficient  to  quiet  pain,  these  means  alone  are  required  to  effect  a 
cure,  perhaps  aided  by  a  light,  hot  flaxseed-poultice  and  a  laxative. 
In  a  few  days  the  patient  can  stand,  and,  by  supporting  his  testicle, 
walk  without  pain. 

In  acute  cases  the  treatment  must  be  more  active.  Eest  on  the 
back  and  elevation  of  the  testicle  over  the  abdomen  are  indispensable. 
The  latter  can  not  be  secured  by  a  suspensory  bandage,  since  that 
supporter  allows  the  testicle  to  hang  down  ;  nor  is  it  well  to  trust  to 
pillows  and  compresses  under  the  testicle,  since  they  allow  the  patient 
no  motion.  No  improvement  on  Curling's  method  has  yet  been  sug- 
gested. It  consists  simply  in  a  handkerchief  or  piece  of  bandage 
around  the  waist,  and  a  large  (preferably  silk)  handkerchief,  folded  in 
triangle.  The  base  of  the  triangle  is  placed  under  the  scrotum  ;  one 
(acute)  angle  on  each  side  is  tied  to  the  waistband,  the  other  (right) 

26 


402  DISEASES  OF  THE   TESTICLE. 

angle  is  brought  up  ovor  the  testicles  and  penis,  serving  to  retain 
dressings,  and  is  pinned  or  tied  to  the  "waistband.  If  the  testicle  be 
not  Yer\'  large,  or  the  patient  move  much,  the  sling  tends  to  slip  up  in 
some  cases.  This  may  be  easily  obviated  by  sewing  a  tape  to  that  })or- 
tion  of  the  sling  immediately  under  the  scrotum,  carrying  it  between 
the  nates  and  attaching  it  at  the  back  to  the  Avaistband. 

In  all  inflammatory  diseases  of  the  testicle  this  bandage  is  of  the 
first  importance.  Having  arranged  it,  the  patient  is  put  to  bed  with 
the  testicle  enveloped  from  the  start  in  a  tobacco-iioultice.  In  cases 
that  require  any  active  treatment  at  all,  and  where  pain  and  swelling 
are  already  present,  any  cold  or  astringent  application  is  harmful. 
The  object  is  to  narcotize  the  testicle  at  once,  and  quiet  pain,  and  this, 
in  the  vast  majority  of  instances,  tobacco,  heat,  and  position  will  do.* 
The  poultice  is  made  by  mixing  a  paper  of  any  line-cut  tobacco  (  |  j) 
in  about  3  x  of  hot  water,  bringing  the  whole  to  a  boil  while  stirring 
it  briskly,  and  then  adding  ground  flaxseed,  with  or  without  ground 
elm-bark,  until  the  proper  consistence  of  a  poultice  is  obtained,  stir- 
ring the  tobacco  well  in  with  the  meal.  A  poultice  of  this  mass  is 
made  about  a  quarter  of  an  inch  thick,  and  large  enough  to  envelop 
the  whole  testicle.  A  piece  of  fine  muslin  is  put  on  the  surface  of  the 
poultice,  which  is  perhaps  sprinkled  with  laudanum,  and  placed  upon 
the  testicle  as  hot  as  it  can  be  borne,  the  whole  covered  with  a  piece  of 
oil-silk — for  cleanliness'  sake  as  well  as  to  retain  the  heat — and  sup- 
ported in  the  handkerchief-sling  above  described.  Ordinarily,  the  tes- 
ticle will  be  narcotized  and  nearly  painless  in  a  few  hours,  unless  the 
patient  attempt  to  stand  upright.  The  poultice  is  to  be  renewed  every 
eight  hours,  and  these  applications  continued  steadily  until  the  indu- 
rated epididymis  has  quite  or  nearly  lost  its  sensitiveness  to  i)rcssure, 
■when  the  patient  may  commence  gradually  going  around,  wearing  a 
suspensory  bandage  containing  some  woolen  batting. 

A  cleaner  and  equally  effective  method  of  narcotization  is  to  rub 
up  into  a  paste  dialyzed  opium  with  oleate-of-zinc  powder,  spread  tliis 
thinly  upon  a  light  poultice  made  of  powdered  elm-bark,  and  apply  ; 
or  powdered  opium  mixed  with  stramonium  ointment  may  be  used,  3  j 
or  3  ij  in  the  1  j  ;  or  hot  opiate  or  belladonna  fomentations. 

I  have  tried  ice,  and  abandoned  it ;  bismuth  paste  is,  I  believe, 
useless  ;  Fourneaux  Jordan's  3  ij  of  nitrate  of  silver  in  the  3  j  of  water, 
painted  once  over  the  entire  scrotum,  has  a  value  in  most  cases,  but  it 
is  quite  painful  for  a  time,  and  often  fails  to  relieve.  The  hot  narcoti- 
zation, I  think,  is  a  better  plan. 

Ordinarily,  the  acute  stage  of  the  disease  requires  not  a  whit  more 
of  treatment  than  this  to  effect  speedy  resolution.     A  laxative,  with  a 

"  The  tobacco-poultice  was  subjected  to  the  test  of  a  thorough  trial  through  many 
years  at  the  New  York  Hospital.  It  proved  itself  more  serviceable  than  any  other 
agent. 


EPIDIDYMITIS— TREATMENT.  403 

tempered  regimen,  is  always  appropriate  where  a  healthy  man  is  sud- 
denly confined  to  his  back. 

In  conditions,  however,  of  extreme  pain,  where  the  disease  is  ex- 
ceptionally acute,  we  have  at  our  command  powerful  means  of  relief. 
When  the  cord  has  become  strangulated,  and  position  does  not  bring 
relief,  from  ten  to  fifteen  leeches  above  the  groin,  along  the  course  of 
the  cord,  will  often  calm  the  pain  as  by  magic.  The  bleeding  should 
be  encouraged  by  the  use  of  hot  water.  This  is  much  more  efficient 
than  the  extraction  of  blood  from  the  scrotum.  Another  cause  of  ex- 
cessive pain,  in  some  cases,  is  extreme  distention  of  the  tunica  vagi- 
nalis with  fluid.  A  puncture  to  let  this  out  is  followed  by  strik- 
ing and  immediate  relief.  Some  authors  advocate  puncture  of  the 
tunica  vaginalis  in  all  cases,  whether  it  be  tensely  distended  or  not, 
stating  that  it  moderates  the  pain  and  shortens  the  attack.  It  is  often 
unnecessary,  and  need  not  be  resorted  to  where  position  and  local  nar- 
cotism suffice  to  quiet  pain,  as  they  usually  will. 

Patients  with  swelled  testicle  are  sometimes  unruly,  and  refuse  to 
go  to  bed,  taking  narcotics  and  wearing  a  poultice  while  they  continue 
at  their  work.  Such  a  course  is  certain  greatly  to  prolong  the  dura- 
tion of  the  attack,  and  to  be  followed  by  chronic  induration  of  the 
epididymis,  which  is  very  apt  to  be  obstinate  and  to  entail  sterility,  as 
far  at  least  as  one  testicle  is  concerned.  Then,  again,  the  imj)atience 
of  restraint,  felt  by  a  man  lying  on  his  back  and  suffering  no  pain, 
often  induces  him  to  leave  his  bed  too  soon,  and  thus  sometimes  a  re- 
lapse is  provoked.  Patients  anxious  about  business  or  concealment 
should  be  advised  from  the  start  that  they  will  save  time  and  trouble, 
and  perhaps  avoid  destroying  the  functional  activity  of  the  testicle, 
by  yielding  to  the  necessities  of  the  case  at  once  and  going  to  bed. 
They  may  be  assured  that  often  four  or  five  days  are  enough,  and  that 
not  more  than  a  week,  or,  in  the  worst  cases,  ten  or  twelve  days  in  bed 
will  be  required,  if  they  will  observe  the  horizontal  position  absolutely 
for  that  period.  In  such  a  case  leeches  to  the  cord,  puncture  of  the 
tunica  vaginalis,  and  diligent  poulticing  will  bring  the  testicle  in  a 
week  to  a  condition  of  comparative  repose,  not  paining  when  let  alone, 
but  still,  perhaps,  several  times  larger  than  its  fellow,  painful  on  ma- 
nipulation and  in  the  erect  posture.  Under  these  circumstances  the 
patient  may  employ  his  time  as  he  chooses,  and  go  about  at  will  if  the 
testicle  be  strapped. 

Strapping  a  testicle  to  reduce  swelling,  first  proposed  by  Fricke,* 
of  Hamburg,  has  not  met  with  the  favor  it  deserres,  for  two 
reasons  : 

1.  It  takes  time,  trouble,  and  some  experience  to  apply  it  so  as  to 
give  comfort  and  be  of  service. 

*  Fricke's  proposition  was  to  strap  a  commencing  swelling,  and  thus  prevent  it.   This 
is  impossible. 


404  DISEASES  OF  THE  TESTICLE. 

2.  If  unskillfullj  applied,  it  either  docs  no  good,  or  causes  pain, 
and  actually  does  harm.     It  has  been  known  to  occasion  gangrene. 

In  declining  epididymitis,  however,  this  agent,  properly  em- 
ployed, is  most  valuable  in  abridging  the  duration  of  treatment. 
When  the  organ  is  still  quite  sensitive  to  pressure,  some  days  before 
the  patient  can  walk  with  comfort,  even  with  his  testicle  suspended, 
if  adhesive  straps  be  carefully  and  snugly  applied,  locomotion  with- 
out pain  is  at  once  possible  (with  a  suspender),  and  there  is  no  fear  of 
a  relapse. 

Strapping  is  performed  as  follows  :  The  hairs  are  cut  from  the 
scrotum  and  strips  of  adhesive  plaster  *  prepared,  from  one  half  to 
three  quarters  of  an  inch  broad  (according  to  size  of  testicle)  and  six 
to  eight  inches  long.  The  patient  now  sits  on  the  edge  of  a  chair  in 
front  of  the  surgeon,  with  his  knees  widely  separated.  The  testicle  is 
caught  in  the  hand,  gently  rolled  and  manipulated  until  the  scrotum 
relaxes  and  the  thumb  and  finger  can  encircle  the  cord  easily  above 
it.  The  position  of  the  encircling  finger  upon  the  scrotum  is  accu- 
rately noted  with  the  eye  ;  the  patient  is  instructed  to  seize  the  testicle 
lightly,  and  hold  it  in  position ;  a  piece  of  bandage  long  enough  to 
encircle  the  testicle,  and  about  two  inches  wide,  is  rapidly  placed 
around  it,  its  center  corresponding  to  that  portion  of  integument 
previously  encircled  by  the  thumb  and  finger,  and  a  strip  of  warmed 
adhesive  plaster  is  placed  at  once  over  the  center  of  the  bandage  be- 
hind and  one  end  brought  round  to  the  front  and  secured.  The  sur- 
geon now  seizes  the  top  of  the  testicle,  draws  lightly  upon  it,  at  the 
same  time  producing  constriction  with  his  thumb  and  finger  above, 
and  with  the  other  hand  pulls  upon  the  free  end  of  jilaster,  brings  it 
rapidly  around  to  the  front,  following  the  central  line  of  the  bandage, 
and  attaches  it  under  tension  to  the  back  surface  of  the  other  end  of 
the  same  strip.  Now  the  testicle  may  be  dropped.  It  will  be  seen  to 
be  covered  by  a  tense,  shining,  perhaps  purplish-looking  integument, 
pretty  tightly  constricted  above  by  a  strip  of  plaster,  the  latter  mar- 
gined all  around  on  both  sides  by  about  three  quarters  of  an  inch  of 
bandage.  The  object  of  the  bandage  (prepared  lint  is  perhaps  better) 
is  to  keep  the  sharp  edge  of  the  adhesive  strip  from  cutting  into  the 
tender  scrotum,  an  accident  which  always  happens  to  a  patient  strapped 
without  this  precaution  who  walks  about,  and  sometimes  even  in 
spite  of  it. 

The  first  strap  is  put  on  tightly  enough  to  cause  a  little  uneasiness. 
It  has  to  be  snug,  or  the  straps  subsequently  applied  would  push  the 
testicle  through  it.  The  remaining  straps  are  adjusted  in  circles,  each 
one  covering  about  half  of  its  predecessor,  and  all  applied  with  a  cer- 

*  Bumstead's  puegcstion  of  two  parts  of  adhesive  plaster  with  one  of  extract  of  bella- 
donna, spread  on  thin  leather,  is  a  good  one.  It  does  away  with  the  necessity  of  any  lint 
or  bandage  under  the  top  strap. 


EriDIDYMITIS— TREATMENT.  405 

tain  degree  of  tension  which  can  only  be  learned  by  personal  experi- 
ence. After  a  number  of  straps  have  been  applied,  it  will  be  found 
that  they  will  no  longer  adhere  (in  a  circular  direction)  to  the  purple, 
tense,  bulging  extremity  of  the  scrotum.  This  portion  is  conse- 
quently covered  in  from  the  sides,  and  from  before  backward,  by 
attaching  a  strip  of  plaster  at  a  given  point,  high  up  over  the  circu- 
lar strips,  bringing  it  down  and  tightly  across  the  bulging  end  of  the 
testicle,  and  attaching  it  high  up  over  the  circular  straps  at  a  point 
exactly  opposite  that  from  which  it  started.  In  this  way,  by  start- 
ing at  successive  points,  the  whole  of  the  exposed  skin  at  the  end  of 
the  testicle  is  covered  tightly  in.  One  or  two  more  circular  straps 
may  now  be  applied  to  keep  the  lateral  ones  from  slipping.  The 
whole  looks  something  like  a  large  cartridge. 

A  certain  amount  of  soreness  follows  this  apparently  rough  hand- 
ling, and  it  is  well  for  the  patient  to  lie  down  again  for  half  an  hour, 
to  find  out  whether  the  strapping  feels  comfortable  or  not.  If  prop- 
erly applied,  comfort  will  have  returned  by  that  time,  and  the  patient 
may  now  place  his  testicle  in  a  suspensory  bandage  to  keep  it  from 
dragging  upon  the  cord,  and  go  around  at  will  without  fear  of  pain  or 
a  relapse.  By  the  mechanical  action  of  the  evenly-adjusted  pressure, 
the  blood  is  kept  as  thoroughly  out  of  his  testicle  as  it  was  by  his  posi- 
tion in  bed.  If  the  straps  cause  pain  after  half  an  hour,  they  should 
be  removed.  Straps  need  to  be  reapplied  every  twenty-four  or  forty- 
eight  hours,  whenever  they  become  loose.  If  they  have  been  care- 
lessly put  on,  any  point  where  the  pressure  is  uneven  will  become 
cedematous.  There  is  habitually  some  oedema  about  the  bottom  of 
the  scrotum  on  removing  the  straps,  but  it  is  of  no  importance.  The 
straps  may  be  detached  by  cutting  each  one  separately,  or  they  may 
be  conveniently  removed  all  at  once  in  a  hot  bath.  After  removal, 
new  straps  should  be  applied  immediately.  Ordinarily,  after  four  or 
five  strappings,  extending  over  as  many  days,  or  perhaps  a  week,  the 
testicle  will  be  found  to  be  reduced  nearly  to  its  natural  size,  a  certain 
amount  of  hardness  still  remaining  in  the  epididymis,  perhaps  con- 
fined to  its  tail.  This  hardness,  as  a  rule,  subsides  spontaneously  in  a 
few  weeks,  in  cases  which  have  been  judiciously  managed  ;  some- 
times, however,  it  remains  for  years.  Its  departure  may  be  hastened 
by  keeping  the  testicle  constantly  in  a  suspender,  covered  by  oil-silk, 
so  as  to  keep  up  slight  constant  heat  and  moisture,  of  course  treating 
any  urethral  disease  which  may  exist.  Sometimes  it  seems  as  if  the 
continued  use  of  mild  mercurial  ointment  under  the  oil-silk  hastened 
the  absorption.  No  known  medicine  is  of  any  proved  service,  iodine 
and  iodide  of  potassium  included.  Tonics  and  cod-liver  oil  do  good 
by  improving  the  quality  of  the  blood. 

To  obtain  the  advantage  and  avoid  the  mechanical  inconveniences 
of  strapping,  several  contrivances  have  been  devised  to  compress  the  tes- 


406  DISEASES  OF  TEE  TESTICLE. 

tide  ;  that  of  Alfred  L.  Carroll,*  a  woven  bag  to  be  laced  up  in  front, 
and  that  of  0.  A.  Wiiite,  f  a  thin  sheet  of  molded  hard  ruliber  to  be 
similarly  laced  np.  are  examples.  The  simplest  method  of  strapping 
is  to  roll  lip  the  testicle  in  an  ordinary  thin  rubber  bandage,  pinning 
it  with  a  safety-pin.  This  does  not  cover  in  the  tail  of  the  testicle, 
but  it  admirably  answers  all  the  necessities  of  ordinary  cases,  is  clean, 
quickly  applied,  safe,  and  can  be  removed  at  will  by  the  patient,  if  re- 
quired. Jesse  Hawes,  J  of  Greeley,  Colorado,  has  devised  a  rubber 
compressor  to  be  laced  in  front,  the  walls  of  which  are  double  and 
capable  of  being  distended  with  hot  or  cold  water,  thus  increasing  the 
pressure  and  applying  heat  or  cold  as  desired.  The  plan  is  a  good 
one,  the  only  objection  being  the  perishable  character  of  rubber  goods. 
Nothing  has  been  said  of  internal  medication  in  the  treatment  of 
epididymitis.  No  medicine  has  any  sjiccific  power  over  it.  Gonor- 
rhccal  treatment  may  be  continued,  as  it  does  no  harm.  Injections 
into  the  urethra  are  best  intermitted,  except  in  cases  of  relapsing  epi- 
didymitis due  to  deep  urethral  inflammation,  in  which  case  deep  ure- 
thral instillations  of  minute  quantities  of  the  nitrate  of  silver  in  solu- 
tion are  often  capable  of  effecting  cure.* 


CHAPTEE    XXY. 

DISEASES   OF  TEE   TESTICLE. 

Psendo-tubercularEpididymitis.— Tubercular  Testis. —Symptoms. —Pathology.— Treatment.— Syphi- 
litic  Epididymitis. —Syphilitic  Orchitis  ;  Interstitial  ;  Gummy.— Cancer.— Sarcoma.— Diagnostic 
Table  of  Syphilitic  Testis,  Tubercular  Testis,  Cancer,  Sarcoma,  including  Diagnostic  Features 
of  Different  Fungi.— Castration.— Dermoid  Cyst.— Irritable  Testis.- Neuralgia  Testis. 

Pseudo-tubercular  Epididymitis  is  very  rare.  It  is  simple, 
slow,  chronic  inflammation.  Desormaux  and  Fournier  |  seem  alone 
to  have  called  esjiecial  attention  to  it.  It  is  peculiar  in  being  observed, 
as  a  rule,  only  in  the  course  of  chronic  urethral  discharges,  and  because 
it  simulates  tubercularization  with  the  most  absolute  accuracy,  so  as 
to  be  usually  mistaken  for  it. 

It  comes  on  during  chronic  urethral  discharge,  often  without  ap- 
preciable, immediate  exciting  cause,  either  as  a  subacute  epidid3'mitis, 
very  indolent  and  not  yielding  to  ordinary  treatment,  or,  even  more 
insidiously,  it  commences  in  an  absolutely  indolent  chronic  form, 

*  "Medical  Record,"  March  19,  1881,  p.  332. 

f  "Boston  Medical  and  Surgical  Journal,"  January  29,  1880. 
X  "Medical  Record,"  Xovember  8,  1884,  p.  529. 

*  Keyes,  "  Xew  York  Medical  Record,"  May  28,  1887. 

I  Art.  "  Diet,  de  Med.  et  de  Cliir.  pratiques."  ' 


TUBERCULAR  TESTIS.  40 7 

simply  characterized  by  knobbed,  irregular  points  of  induration  in 
the  epididymis,  slightly  sensitive  to  pressure.  The  swelling  increases 
slowly,  but  the  pain  ceases,  until  after  a  time  we  may  have  a  large, 
knobbed,  irregular  epididymis,  a  healthy  testicle,  more  or  less  fluid  in 
the  tunica  vaginalis,  and,  perhaps,  the  vas  deferens,  which  not  infre- 
quently participates  in  the  disease,  swollen  to  the  size  of  a  pipe-stem, 
hard,  slightly  sensitive  to  pressure,  smooth,  or  knotty  and  irregular. 

There  is  now  a  strong  tendency  to  suppuration,  and  one  or  more 
abscesses  may  form  in  the  epididymis,  or  possibly  in  the  vas  deferens, 
and  discharge  externally.  Such  abscesses  long  remain  fistulous,  and 
closing  leave  a  nodosity  which  is  slow  to  disappear.  Sometimes  matter 
forms  near  the  tail  of  the  epididymis,  but  the  abscess  finally  dries  up 
without  discharging.  This  may  leave  a  hard,  insensitive  shot  or  mar- 
ble-like lump,  freely  movable  in  the  scrotum,  and  connected  with  the 
tail  of  the  epididymis  by  a  pedicle.  Such  curiosities  are  occasionally 
encountered.  Sometimes  resolution  is  effected  after  many  weeks,  per- 
haps months,  without  suppuration. 

The  treatment  is  hygienic  and  tonic,  in  fact  exactly  the  same  as  for 
tubercular  epididymitis,  but  with  more  hope  of  ultimate  success. 

TUBERCUIiAE,    TESTIS. 

Tubercular  disease  of  the  testis  is  usually  described  as  occurring  in 
two  forms — one  as  a  continuation  and  degeneration  of  chronic  inflam- 
matory thickening,  left  behind  by  previous  disease ;  the  other  spon- 
taneous, tuberculization  coming  on  without  apparent  local  cause,  and 
unconnected  with  any  urethral  disease.  The  first  of  these  forms  has 
been  described  above  as  pseudo-tubercle.  It  always  affects  the  epididy- 
mis primarily,  may  extend  thence  to  the  vas  deferens  and  seminal 
vesicles,  and  finally  involve  the  testis  proper  as  well.  It  is  distin- 
guished under  a  different  head  from  tubercle  proper.  Its  prognosis  is 
much  better.  If  not  arrested,  however,  its  advanced  stages  may  be 
identical  with  those  of  true  tubercular  testis,  and  its  terminations  the 
same.  The  pathology  of  the  affection  is  cheesy  degeneration  of  in- 
flammatory products  effused  inside  of,  as  well  as  outside  of,  the  seminal 
passages. 

Tubercular  testis  ]oroper  has  certain  peculiarities  of  its  own.  Its 
pathology  is  cell-proliferation,  totally  outside  of  the  tubes  and  ducts 
(Rindfleisch).*  Malassez  gives  the  endothelium  a  share  in  the  forma- 
tion of  tubercle.  His  views  are  well  set  forth  in  an  exhaustive  mono- 
graph, containing  bibliography  to  date,  by  P.  Eeclus.f  Tubercle  of 
the  testis  is  less  common  in  the  miliary  form,  but  it  does  occur  (Vir- 
chow).     Tubercular  disease  of  the  testicle,  in  cases  where  it  does  not 

*  "  Histological  Pathology,"  2d  edition. 

t  "Du  Tubercule  du  Testicule,"  Paris,  1876. 


408  DISEASES  OF  THE  TESTICLE. 

follow  gonorrlioeal  or  other  epididymitis  as  a  sequence  of  chronic 
or  of  pseudo-tubercular  disease,  comes  on  without  ai)preciable  pro- 
Tokiug  cause  in  lymphatic,  strumous,  or  tubercular  subjects,  some- 
times in  young  men  apparently  perfectly  healthy.  It  is  most  liable 
to  appear  during  early  manhood  just  after  puberty,  when  the  phy- 
siological activity  of  the  gland  is  most  marked.  It  may  apjiear  in 
childhood. 

Si/mpfoms. — The  deposit  takes  place  by  preference  in  the  epididy- 
mis, but  the  secreting  structure  usually  also  suffers  later  (Rindfleisch). 
There  is  no  jjain,  so  that  it  is  usual  for  the  disease  to  pass  unnoticed 
until  by  accident  the  patient's  attention  is  attracted  by  the  fact  that 
one  testicle  is  larger  than  the  other.  Sometimes,  where  the  deposit  is 
rapid,  slight  pain  is  experienced.  On  examining  such  a  testicle,  it  is 
usually  found  large,  hard,  and  lumpy  behind  ;  but  the  Avhole  organ  is 
often  also  hard,  irregular,  unevenly  nodular.  There  is  perhaps  some 
fluid  in  the  tunica  vaginalis,  obscuring  the  outline  of  the  testis.  The 
vas  deferens  is  often  knotty,  enlarged,  and  hard  as  far  as  it  can  be  felt, 
and  a  finger  in  the  rectum  may  detect  the  seminal  vesicle  similarly 
affected.  There  may  also  be  (more  rarely)  tubercular  prostatitis  or 
evidences  of  tubercular  kidney.  The  testicle  feels  heavy,  the  skin 
over  it  is  unaltered,  pressure  does  not  cause  pain  (unless  abscess  be 
forming),  nor  does  it  occasion  the  sensation  felt  when  the  healthy  testis 
is  squeezed.  It  is  not  uncommon  for  both  testicles  to  be  affected,  the 
one  in  a  more  advanced  stage  than  the  other.  If  botli  are  involved, 
the  sexual  ajipetite  is  usually  reduced  or  absent.  The  malady  advances 
slowly,  sometimes  remaining  stationary  for  many  months  ;  finally  the 
nodules  soften  into  abscess ;  the  skin  becomes  oedematous,  adheres 
over  the  epididymis,  the  patient  has  a  little  pain  for  a  few  days,  when 
the  abscess  bursts  and  discharges  a  thick,  cheesy  material,  containing, 
if  the  body  of  the  testicle  has  ulcerated,  portions  of  necrosed  seminal 
tubules  from  time  to  time. 

These  abscesses  remain  fistulous  for  a  long  time,  sometimes  indefi- 
nitely, the  fistulous  tract  being  marked  by  great  induration  from 
chronic  inflammation.  New  abscesses  tend  to  form,  pointing  by  old 
or  new  routes.  After  abscess  of  the  substance  of  the  testis,  hernia 
testis  may  come  on,  and,  when  the  disease  mounts  the  cord,  the  in- 
guinal glands  are  not  infrequently  enlarged.  These  cases  are  often 
mistaken  for  cancer,  and  as  such  extirpated  and  recorded  as  fortunate 
cases  of  removal  of  cancer  with  no  return  of  the  disease.  A  patient 
may  have  both  testicles  indurated,  knobbed,  full  of  fistulas  for  years, 
and  still  seem  to  be  enjoying  excellent  health,  witli  the  exception  of 
more  or  less  loss  of  sexual  desire  and  power,  but  usually  he  is  pale, 
thin,  anaemic,  weak,  perhaps  with  tubercular  deposits  in  his  lungs  or 
elsewhere. 

For  differential  diagnosis,  see  table  after  Sarcoma.     As  to  prog- 


TUBERCULAR  TESTIS— TREATMENT.  400 

nosis,  a  tubercular  testicle  is  not  necessarily  lost.  Pseudo-tubercular 
disease  also  is  often  indistinguishable  from  it. 

Pathology. — Tubercular  nodules  arc  developed  in  the  connective 
tissue  (or  lymph  canals)  around  the  seminal  tubes  and  ducts.  These 
partly  organize  into  fibrous  tubercles.  The  tubercles  coalesce  into 
large  masses,  dirty  yellow  on  section,  in  direct  connection  with  healthy 
tissue,  not  encysted  ;  and  then,  their  vitality  being  low,  cheesy  de- 
generation of  the  center  takes  place.  After  a  variable  period  the  mass 
breaks  down,  and  is  partly  eliminated  by  abscess. 

Kindfleisch,  following  Langhans  and  Klebs,  believes  tubercle  to  be 
the  result  of  endothelial  proliferation  in  the  lymphatic  spaces  sur- 
rounding the  seminal  tubules. 

Terrillon  and  Lebreton*  have  collected  from  various  Frencli 
sources  cases  of  primary  tubercle  of  the  testicle,  where  the  patients 
were  followed  until  death  and  autopsies  made,  33  in  all,  of  which 
there  died  :  26  by  consecutive  tubercular  disease  of  bladder  and  kid- 
neys ;  1  by  consecutive  tubercular  disease  of  lung  and  peritongeum  ; 
3  by  consecutive  tubercular  disease  of  peritonaeum  ;  3  from  accidental 
cause  ;  and  1  not  accounted  for. 

Thompson's  statistics  of  18  cases  give  8  by  general  genito-urinary 
tuberculosis,  7  by  renal  and  pulmonary  tuberculosis,  and  3  by  pulmo- 
nary tuberculosis  alone. 

The  conclusions  of  Reclus  are  indorsed  that  primary  tuberculosis 
of  the  testis  is  a  grave  source  of  danger  and  a  focus  of  general  infec- 
tion, and  consequently  that  castration  ought  to  be  performed  early. 
Lancereaux,  f  on  the  contrary,  disagrees  with  Eeclus,  and  states  that 
tubercle  is  never  primary  in  the  testicle,  that  it  always  begins  in  the 
prostate  and  goes  from  thence  to  the  seminal  vesicle,  then  to  the  tes- 
ticle, that  it  is  consequently  always  a  general  disease  from  the  first, 
and  that  it  is  not  proper  to  remove  the  testicle. 

Treatment. — In  tubercular  disease  of  the  testis  the  treatment  ap- 
plied may  save  not  the  patient's  life,  for  that  is  rarely  implicated,  but 
his  sexual  power,  his  peace  of  mind,  and  may  give  life  to  his  children. 
It  is  hard  to  convince  such  patients  that  medicine  is  not  the  best  thing 
for  them,  and  they  suffer  so  little  pain  that  they  are  slow  to  see  the 
necessity  of  giving  up  their  business  and  living  an  easy  out-door  life  in 
the  country,  or,  better  still,  of  transplanting  themselves  to  one  of  the 
high  inland  resorts  where  the  climate  and  surroundings  are  hostile  to 
tubercle.  Some  patients,  unfortunately,  can  not  follow  this  course, 
and  their  case  is  sad  indeed.  Others  can,  but  will  not  recognize  the 
necessity  of  it. 

The  chances  are  not  encouraging  or  the  hope  very  great,  but  in  all 
cases  where  there  is  a  hope  that  the  disease  may  be  pseudo-tubercular, 

*  "Ann.  des  Mai.  des  Org.  Genito-urinaires,"  Jan.  and  Feb.,  1883,  pp.  142-162. 
t  "Ann.  des  Mai.  des  Org.  Genito-urinaires,"  Jan.,  1883,  p.  153. 


410  DISEASES  OF  THE  TESTICLE. 

Tvhere  only  the  epididymis  is  inyolvcd,  tlie  testicle  being  healthy,  where 
onlv  one  organ  is  affected  or  even  where  both  sutler,  but  the  disease  has 
not  advanced  far,  the  surgeon's  duty  is  pUiinly  to  throw  the  whole 
wejo-ht  of  his  influence  into  the  scale,  to  induce  the  patient  to  flee  into 
the  country,  to  change  his  air  and  his  surroundings,  and  to  observe  all 
the  conditions  of  johysical  liygicnc  suitable  to  tubercular  cases.  A  sus- 
pensory bandage  is  useful,  with  the  testicle  enveloped  in  oil-silk. 

Tliese  means  exhaust  our  best  resources.  Local  dressings  to  the 
testicle  are  of  no  avail,  except  to  amuse  and  satisfy  the  patient.  If 
abscess  form,  it  should  be  poulticed,  and  induced  to  point  quickly,  the 
other  treatment  being  followed  unremittingly.  Old  abscesses,  tuber- 
cular cavities,  and  cheesy  foci,  with  all  fistular  communications,  should 
be  laid  freely  open  and  very  thoroughly  scraped.  Castration  in  my 
opinion  should  not  be  performed  until  the  testicle  is  absolutely  disor- 
ganized. The  danger  of  general  infection  is  not  very  great.  This 
advice  applies  more  positively  to  cases  in  Avhich  both  testicles  are  in- 
volved. When  the  disease  is  unilateral,  castration  is  allowable  for  less 
serious  local  disease  than  when  both  organs  are  tubercular.  The  rea- 
sons for  this  are  obvious.  Cod-liver  oil,  the  hypophosphites,  phos- 
phate of  lime,  iron — especially  the  iodide — quinine,  cinchona,  and  to 
the  end  of  the  chapter,  are  of  service  as  general  tonics.  Arsenic  has 
value,  and  possibly  iodide  of  potassium  a  little.  The  latter  has  been 
greatly  overrated.  Mercury  is  of  no  service.  Both  mercury  and  iodine 
have  undoubtedly  derived  their  reputation  from  curing  cases  where 
a  syphilitic  testicle  has  been  believed  to  be  tubercular,  a  mistake  some- 
times not  easy  to  avoid  in  obscure  cases.  The  rule  of  treatment  in 
tubercular  testis  is  imperative.  Do  not  lose  time  by  trying  drugs. 
Let  the  patient  get  a  change  of  air  at  any  sacrifice  to  himself,  and  let 
him  take  his  medicine  while  he  is  using  the  stronger  agents,  intelligent 
hygiene  and  dietetics. 

SYPHTLITIC    TESTIS. 

Syphilitic  disease  of  the  testicle  *  has  become  of  late  years  a  well- 
recognized  affection,  and  has,  indeed,  absorbed  into  itself,  according  to 
agreement  by  most  modern  authors,  most  of  the  cases  which  were 
formerly  described  as  chronic  inflammation  of  the  secreting  portion  of 
the  testicle.  It  is  not,  indeed,  too  much  to  say  that  perhaps  all  cases  of 
chronic  enlargement  of  the  testicle  of  a  seemingly  inflammatory  origin, 
excepting  such  as  are  left  behind  by  previous  acute  inflammation,  when 
not  due  to  cancer  or  tubercle,  are  syphilitic,  although  there  may  be  at 
the  time  no  other  evidence  of  syphilis  upon  the  patient,  and  may  not 
have  been  for  years.     For  distinguishing  marks  of  these  forms  of  en- 

*  Rcclus  has  an  admirable  article  on  the  testicle,  in  which  the  syphilitic  affections 
are  clearly  explained,  in  the  "  Diet.  Encyc.  des  Sciences  Medicales." 


SYPIIILITIG   ORCHITIS.  411 

largement,  see  diagnostic  table.     There  are  two  forms  of  syphilitic 
testis  : 

1.  Syphilitic  epididymitis. 

2.  Syphilitic  orchitis,  diffuse  and  gummy. 

1.  Syphilitic  Epididymitis. — An  exhaustive  description  of  this 
affection  was  first  furnished  to  the  profession  by  Dron,*  who  gives  a 
number  of  cases.  Other  authors  have  since  described  the  disease.  No 
autopsy  has  yet  revealed  its  exact  pathology,  but  an  identity  of  lesion 
with  other  syphilitic  affections  of  the  testicle  is  probable.  It  is  of  rare 
occurrence.  It  comes  on  usually  in  the  early  months,  at  a  mean  of 
about  three  or  four  months  after  chancre,  during  the  period  of  the 
early  eruptions.  Bassereau  and  Eollet  have  seen  it  coincide  with 
roseola.  The  disease  is  confined  to  the  epididymis,  mainly  to  the 
globus  major.  The  epididymis  may  suffer  with  the  testicle  in  the 
later  forms  of  syphilitic  orchitis,  but  in  this  earlier  form  the  testicle 
is  only  involved  in  a  small  minority  of  cases.  Lancereaux  states,  as  a 
general  rule,  that  the  earlier  syphilis  attacks  the  testicle  the  more 
liable  is  the  epididymis  to  suffer.  This  syphilitic  epididymitis  has 
been  observed  (very  rarely)  as  late  as  several  years  after  chancre. 
The  disease  usually  involves  both  sides  at  the  same  time.  I  have  en- 
countered it  a  number  of  times,  but  always  confined  to  one  side.  In 
one  such  case,  Dron  examined  the  semen  of  a  patient  and  found  sper- 
matozoa. This  test  might  be  of  service  in  doubtful  cases  to  differen- 
tiate the  disease  from  ordinary  chronic  epididymitis,  although  in  the 
latter  it  is  the  tail  and  not  the  head  of  the  epididymis  which  is  gener- 
ally involved,  and  there  has  been  almost  invariably  some  urethral  dis- 
charge preceding  the  attack.  Furthermore,  this  syphilitic  induration 
of  the  globus  major  stands  out  clearly  defined  as  a  hard  tumor,  en- 
tirely distinct  from  the  testicle,  and  not  capped  over  it  as  is  usually 
the  case  in  chronic  epididymitis.  The  swelling  is  indolent,  accom- 
panied by  an  insignificant  amount  of  pain.  All  reported  cases  have 
ended  in  resolution  ;  it  never  suppurates,  but  declines  rapidly  under 
the  appropriate  treatment  of  early  syphilitic  lesions  (mercurial).  Eol- 
let puts  the  limits  of  treatment  necessary  at  from  fifteen  days  to  two 
months.  Local  means  are  not  necessary.  No  functional  alteration 
or  organic  lesion  is  left  behind.  Dron  saw  the  malady  once  in  the 
globus  minor. 

2.  Syphilitic  Oechitis. — This  affection  appears  under  two  forms  : 
a.  Diffuse,  chronic,  interstitial  inflammation  of  the  organ,  of  a 

peculiar  sort. 

I.  Gummy  nodules ;  the  latter  being  an  intensification  of  the 
former  process,  often  accompanied  by  it,  but  of  the  two  forms  the 
more  rare. 

*  "De  rEpididymite  syphilitique,"  Archives  Gen.,  Sixth  Series,  vol.  ii,  Xovember  and 
December,  1863,  pp.  513  and  '724. 


412  DISEASES  OF  THE  TESTICLE. 

a.  The  diffuse  form,  like  interstitial  lie]):ititis,  or  nephritis,  is 
an  interstitial  orchitis,  a  peculiar  sort  of  chronic  inliammation  attack- 
ing the  fibrous  envelope  and  the  septa  of  the  organ.  Kicord  named 
it  albuginitis.  The  process  begins  by  hyperemia  ;  young  cells  appear 
in  the  coiinectiye  tissue  of  the  organ,  many  of  tliem  develo])ing  into 
fibers  which  go  on  to  contract.  These  young  cells  press  upon,  and 
gradually  cause  atrophy  of,  the  tubular  structure.  The  tunica  albu- 
ffinea  becomes  thickened,  as  does  also  the  tunica  vasinalis.  More  or 
less  lluid  occupies  the  cavity  of  tlic  latter,  wliile  many  adhesions  com- 
monly take  place  between  the  free  surfaces.  In  this  way  the  organ 
reaches  double  its  natural  size,  perhaps  more,  but  rarely  becomes  very 
large,  unless  from  a  considerable  collection  of  fluid  in  the  tunica  vagi- 
nalis. Often  only  a  portion  of  the  gland  is  involved  in  these  changes. 
Both  testicles  may  be  affected  simultaneously,  but  usually  consecu- 
tively. After  a  time  the  newly-formed  connective  tissue  contracts, 
the  septa  between  the  lobes  of  seminal  tubules  become  greatly  thick- 
ened, composed  of  dense,  fibrous  tissue,  showing  white  on  section, 
while  the  clusters  of  tubules  intervening  between  them,  after  first 
undergoing  a  brown  pigmentation,  become  atrophied  by  pressure,  and 
finally  may  disappear,  lost  in  the  general  fibrous  metamorphosis  of  the 
gland.  The  contraction  may  continue,  much  of  the  newly-formed 
material  being  absorbed,  and  the  process  going  on  to  wasting  of  the 
organ,  until  only  a  stump  is  left  behind.  If  the  gland  has  only  been 
l^artially  invaded,  a  depression  may  be  left  marking  the  site  of  the  dis- 
ease. In  this  form  there  is  no  tendency  to  suppuration,  ulceration,  or 
formation  of  fungus.     This  is  the  slower  variety  of  disease. 

b.  TJie  (jummy  form,  which  is  believed  to  be  an  intensification  of 
the  foregoing  process,  sometimes  coexists  with  it.  It  is  marked  by 
the  formation  of  nodules,  usually  multiple,  which  seem  often  to  take 
their  origin  in  the  external  tunic  of  a  vessel,  or  the  wall  of  a  sper- 
matic tubule  (Lancereaux).  They  may  be  found  of  all  sizes,  from  a 
mere  point  to  that  of  an  egg,  and  consist  of  an  agglomeration  of  cells, 
with  more  or  less  fatty,  granular  matter,  toughly  united  by  fibrous 
elements  into  a  lump,  presenting,  on  section,  a  grayish-yellow  or  dis- 
tinct dark-yellow  color.  As  they  get  larger  these  nodules  tend  to 
soften  at  the  center.  They  are  surrounded  by  a  grayish  areola,  trav- 
ersed by  vessels,  and  later  are  often  enveloped  by  a  condensation  of 
tissue  somewhat  resembling  a  capsule.  These  tumors  may  form  near 
the  surface,  or  deep  in  the  gland.  They  may  occur  in  the  epididymis. 
The  latter,  however,  usually  escapes,  while  the  vas  deferens  is  very 
rarely  involved.  The  tunica  vaginalis  is  usually  more  or  less  distended 
with  fluid.  In  gummy  orchitis  the  testicle  may  acquire  a  very  large 
size.  I  have  seen,  in  connection  with  syphilitic  testis,  the  gummatous 
form,  an  implication  of  the  entire  epididymis  with  the  development 
of  thickened  plates  of  induration  in  the  tunica  vaginalis.     I  have  seen 


SYPHILITIC   ORCHITIS— SYMPTOMS.  413 

these  plates  nearly  a  quarter  of  an  inch  thick,  and  half  as  large  as  the 
palm  of  the  hand,  in  a  case  of  enormously  enlarged  testicle,  gumma- 
tous and  diffuse,  complicated  also  by  hydrocele.  The  latter  got  well 
under  carbolic-acid  injection,  the  testicle  recovered,  and  the  plates  dis- 
appeared under  internal  mixed  treatment  with  iodides  in  excess.  I 
have  seen  many  other  examples  of  the  implication  of  the  epididymis 
in  combination  with  these  indurated  plates  in  the  tunica  vaginalis,  and 
have  come  to  look  upon  them  as  characteristic  of  syphilis,  as  they 
always  disappear  under  mixed  treatment.  The  gummy  tumors  once 
formed  may  cease  to  grow,  soften,  degenerate,  and  calcify,  or  be  en- 
tirely absorbed,  leading  to  atrophy,  perhaps,  of  the  whole  organ,  or 
only  of  a  portion.  Again,  the  integument  over  them  may  ulcerate 
after  adhesion  has  taken  place,  and  syphilitic  fungus  result. 

The  mechanism  of  the  formation  of  fungus  is  as  follows  :  The 
gammy  matter  infiltrates  the  tunica  albuginea,  and  undergoes  degen- 
eration, causing  softening  of  that  structure,  with  bulging  of  the  con- 
tents of  the  testicle.  The  suprajacent  skin  and  intervening  tissues 
now  inflame  and  adhere,  finally  ulcerating  and  allowing  the  continu- 
ous growth  of  gummy  matter  within  the  testis  to  extrude  through  the 
opening,  together  with  the  tubular  structure,  which  may  be  found 
lying  in  little  clusters  amid  the  yellow  material.  The  fungus  contin- 
ues to  grow,  the  dartos  and  skin  contract  about  its  pedicle,  and  the 
extruded  mass  becomes  covered  with  some  granulation  tissue,  and 
bathed  in  pus.  These  syphilitic  fungi  are  rather  firm  to  the  feel, 
painless,  and  do  not  bleed  very  easily.  If  cut  off  they  continue  to 
grow,  or,  if  the  disease  be  not  arrested,  the  sprouting  may  continue 
until  the  whole  tubular  structure  of  the  testis  has  been  pushed  out 
from  the  inside,  after  which  it  may  wither  and  dry  up,  the  testicle 
going  into  complete  atrophy.  The  seminal  tubes  in  the  fungus  retain 
some  of  their  activity,  as  shown  by  the  fact  that  spermatozoa  may  be 
found  in  the  discharge.  The  fungus  differs  from  other  fungi  of  the 
testis.  After  injury  some  of  the  tubules  may  protrude  as  a  slough, 
but  whatever  fungus  there  is  is  simple  granulation,  soft,  bright,  pink, 
bleeding  easily.  (For  differential  diagnosis  of  fungi  of  testicle,  see 
DiAG]srosTic  Table.) 

Syfnptoms. — True  syphilitic  orchitis,  affecting  the  body  of  the 
testis,  rarely  appears  until  after  at  least  a  year,  rarely  before  the  third 
year  has  elapsed  from  the  date  of  chancre.  It  may  be  occasionally 
more  precocious.  Eicord  and  Bumstead  have  seen  it  as  early  as  the 
fourth  or  fifth  month.  It  may  coincide  with  iritis,  with  groups  of 
tubercles,  with  ulcers,  or  deeper  lesions  of  bone  or  cartilage.  ISTot  in- 
frequently, however,  it  comes  on  long  after  the  patient  has  ceased  to 
show  any  evidence  of  specific  disease.  The  enlargement  of  the  testis 
takes  place  gradually  and  without  pain.  It  is  usually  first  discovered 
by  accident,  already  quite  large,  so  that  the  patient  affirms  that  the 


414  DISEASES  OF  THE  TESTICLE. 

swelling  came  on  very  rapidly,  in  a  day  or  more.  There  may  be, 
however,  some  sligiit  pain  at  tirst,  especially  along  the  cord,  and  in 
the  groin,  with  an  uneasy  feeling  in  the  testicle  itself.  When  first 
seen,  the  size  of  the  testicle  is  usually  not  more  than  twice  or  three 
times  as  large  as  natural.  It  may  be  perfectly  smooth,  and  hard  as 
wood,  the  epididymis  not  distinguishable.  Sometimes  the  body  of  the 
testis  is  irregular  and  nodular,  very  hai'd,  or  there  may  be  one  or  more 
prominent  lumps  of  gummy  exudation.  Only  a  portion  of  the  testi- 
cle may  be  involved,  the  rest  feeling  natural.  In  such  a  case  the 
healthy  portion  may  be  normally  sensitive,  giving,  when  pressed,  the 
natural  sensation  of  squeezing  the  testicle.  Often,  however,  the  swell- 
ing is  wholly  insensitive,  and  may  be  squeezed  at  will,  without  evoking 
the  least  uneasy  feeling. 

The  outlines  of  the  testicles  may  be  obscured  by  a  considerable  col- 
lection of  fluid  in  the  tunica  vaginalis.  After  drawing  this  off,  the 
hard,  nodular,  uneven  outline  of  the  insensitive  syphilitic  testis  be- 
comes api^arent.  The  vas  deferens  is  nearly  always  healthy,  and  the 
scrotal  tissues  rarely  involved,  so  that  the  hard  mass  can  be  freely 
moved  and  examined  under  the  thin  skin  of  the  scrotum.  I  have 
seen  a  case  in  which  the  cord  was  also  involved,  the  vas  deferens  be- 
ing thickened  to  the  size  of  a  lead-pencil,  smooth,  hard,  painless. 
Fournier  *  also  records  a  case,  and  Desprcs  \  another. 

The  general  health  may  appear  excellent,  but,  if  both  testicles  are 
involved,  sexual  appetite  and  power  are  almost  invariably  absent. 
There  are  no  erections,  and  function  is  temporarily  abolished.  The 
same  impairment  of  sexual  funcftion  exists  in  a  less  degree  where  one 
gland  only  is  involved.  There  may  be,  very  rarely,  a  syphilitic  fun- 
gus, as  described  above.  The  glands  in  the  groin  are  not  affected. 
(For  differential  diagnosis,  see  Diagxostic  Table.) 

The  duration  of  the  disease  may  extend  over  several  years.  The  ter- 
minations are  resolution,  degeneration  (fibrous,  fatty,  calcific),  atrophy. 

Prognosis. — The  prognosis  is  good.  The  seminal  tubules  do  not 
become  occluded.  They  only  perish  by  degeneration  and  atrophy, 
from  pressure,  and  some  of  the  canaliculi  have  usually  escaped.  The 
sooner  treatment  is  commenced,  the  better  the  prognosis.  The  gum- 
my material  melts  away  under  appropriate  measures,  liberating  from 
pressure  such  of  the  tubules  as  have  escaped  atrophy,  and,  with  a  re- 
turn of  the  organ  to  its  natural  size,  erections  and  sexual  appetite  re- 
appear. Gosselin  has  found  spermatozoa  in  the  semen  of  patients 
who  had  had  double  syphilitic  orchitis  after  the  same  had  been  cured 
by  treatment.  Eclapse  is  always  to  be  feared,  especially  if  the  treat- 
ment be  not  persisted  in  long  enough,  or  if  the  testicle  be  subjected 
to  mechanical  violence  when  nearly  cured. 

*  "  Sarcoc^le  syphilitique,"  Paris,  1875. 

t  "  Bull-  dc  la  "Soc.  de  Chir.,"  1875,  1,  2,  p.  140. 


SYPHILITIC   ORCHITIS— TREATMENT.  415 

Treatment. — All  three  forms  of  syphilitic  testis  arc  amenable  to 
treatment.  Early  syphilitic  epididymitis  gets  well  promptly  under 
mercury,  employed  as  for  the  earlier  syphilidcs.  Of  the  other  two 
forms,  the  purely  gummy  may  be  more  promptly  relieved  ;  but,  in 
any  case,  the  earlier  an  intelligent  treatment  is  instituted  the  more 
speedily  does  the  disease  respond.  The  mixed  treatment  is  most  com- 
monly applicable — mercury  and  iodide  of  potassium  ;  but,  as  a  gen- 
eral rule,  the  later  the  attack  after  the  chancre  the  more  reliance  is  to 
be  placed  upon  the  iodide,  and  the  less  upon  mercury.  With  dis- 
tinct, large-knobbed,  gummy  tumors,  and  always  with  syphilitic  fun- 
gus, and  in  connection  with  other  marked  evidences  of  tertiary  dis- 
ease, the  iodide  should  be  used  alone,  carried  rapidly  to  a  high  dose. 
(See  Treatment  of  Syphilis.)  A  suspensory  bandage  should  be 
worn,  and  all  hygienic  means  employed.  Local  treatment  is  unneces- 
sary. 

Fungus  may  be  touched  with  nitrate  of  silver,  and  strapped  after 
any  constriction  at  its  neck  by  the  scrotal  tissues  has  been  divided ; 
but  reliance  can  only  be  placed  on  internal  treatment,  which  will 
cause  it  to  shrink  back  into  its  place.  It  is  unwise  to  cut  away  any 
portion  of  it,  for  healthy  seminal  tubules  may  thus  be  sacrificed.  It 
is  needless  to  add  that  no  attempt  need  be  made  to  cure  the  accom- 
panying hydrocele.  The  fluid  will  disappear  as  the  testicle  reduces  in 
ordinary  cases  in  size,  and  no  injections  or  other  local  measures  need 
be  called  into  play.  As  often  as  the  tunica  vaginalis  become  distended 
a  palliative  puncture  may  be  resorted  to.  If  occasionally  the  hydro- 
cele persist  after  the  testicle  has  returned  to  a  state  of  health,  it  may 
then  be  treated  successfully  by  the  ordinary  methods.  Sometimes  a 
syphilitic  testicle  is  first  suspected,  after  the  evacuation  of  a  hydro- 
cele, by  the  characteristic  feel  of  the  gland.  Extirpation  is  not  to  be 
thought  of.  Before  syphilitic  disease  of  the  testicle  was  understood, 
the  older  surgeons  were  in  the  habit  of  extirpating  many  large,  chron- 
ic, indolent  swellings  of  the  organ  (called  sarcocele,  or  hydro-sarco- 
cele),  which  an  appropriate  treatment  might  have  restored.  Sir  Ast- 
ley  Cooper  at  one  time  gave  it  as  a  general  rule  that  no  testicle  should 
be  removed  for  chronic  enlargement  and  induration  until  '^the  gums 
had  been  touched  by  mercury."  Modern  progress  has  altered  the 
rule.  We  no  longer  "  touch  the  gums,"  but  it  may  now  be  safely 
laid  down  as  a  proper  rule  to  follow,  in  all  cases  of  douht,  with  en- 
largement of  the  testicle,  never  to  operate  until  a  thorough  antisyphi- 
litic  treatment  has  heen  tried  faithfully,  including  large  doses  of  the 
iodide  of  potassium.  A  final  caution  must  be  given,  namely,  not  to 
remit  treatment  too  soon.  It  should  be  kept  up  for  many  months 
after  the  testicle  has  resumed  its  natural  size,  and  only  given  up  grad- 
ually, for  fear  of  relapse. 


416  DISEASES  OF  THE  TESTICLE. 

CANCER   OF    THE   TESTICLE. 

Soft  carciuomii  is  the  only  variety  of  cancer  occurring  primarily  in 
the  testis.  Scirrhus  lacks  the  "strict  requirements  of  anatomical 
proof."  *  XcpveUjf  however,  details  tliree  personal  cases  of  undoubted 
scirrhus,  and  cites  six  other  cases  from  various  sources.  The  course  of 
the  malady  is  slow,  averaging  six  years ;  the  testicle  may  be  increased 
or  diminished  in  size.  Pigmented  cancers  are  said  to  have  been  seen 
as  metastases.  But  even  soft  cancer  is  very  rare.  It  does  occur,  how- 
ever, and  is  found  at  all  ages  from  the  cradle  to  the  grave.  Pitha 
saw  it  in  a  new-born  infant.  After  sixty  it  is  very  uncommon.  It  is 
met  with  mainly  in  early  manhood,  when  the  function  of  the  testicle 
is  most  active.  It  rarely  occurs  on  both  sides.  An  injury  seems 
sometimes  to  be  the  immediate  exciting  cause.  Sarcomatous  tumors 
of  the  testis  are  very  liable  to  degenerate  after  a  time,  and  become  car- 
cinomatous. 

Symptoms. — Gradually,  sometimes  rapidly,  induration  and  enlarge- 
ment come  on.  The  oval  shape  is  preserved,  there  is  only  slight  pain 
(worse  on  pressure  throughout  the  disease),  and  there  is  effusion  into 
the  tunica  vaginalis.  As  the  testis  grows,  it  becomes  uneven  on  its 
surface,  elastic  in  portions,  perhaps  so  soft  as  to  give  the  idea  of  true 
fluctuation.  The  pain  now  increases  in  the  testicle  and  cord,  the  lat- 
ter becomes  engorged,  the  pelvic  and  abdominal  glands,  as  also  often 
the  inguinal,  swell,  and  become  cancerous.  The  tumor  formed 
by  these  glands  may  usually  be  felt  in  the  loins.  There  is  generally 
constant  pain  in  this  region.  Venous  circulation  is  impeded  by  i^ress- 
ure  of  the  cancerous  masses  upon  the  great  abdominal  veins,  the 
veins  of  the  scrotum  stand  out  varicose  and  prominent,  the  leg  be- 
comes (edematous.  The  pains  become  intense,  sharp,  shooting,  often 
burning  in  paroxysms,  between  which  a  constant  ache  is  felt  in  the 
testicle  and  cord.  The  testicle  during  this  period  has  been  constantly 
growing,  it  has  burst  the  bounds  of  the  tunica  albuginea,  involved  the 
epididymis  and  cord,  but  the  scrotum  expands  and  the  tumor  may 
reach  the  size  of  a  child's  head.  Boyer  removed  a  cancerous  testis 
weighing  nine  pounds.  During  its  growth  it  may  experience  periods 
of  rest  when  there  seems  to  be  little  or  no  advance  made,  or  when  it 
may  become  smaller  for  a  time,  by  the  absorption  of  some  fluid  por- 
tions, as  of  fluid  in  the  tunica  vaginalis.  The  pain  is  aggravated  by 
pressure,  and  the  normal  feeling  on  pressure  is  absent.  After  a  time, 
if  death  or  an  operation  do  not  remove  the  tumor,  the  scrotum  will 
adhere  to  it  at  some  one  or  more  prominent  portions,  the  skin  will  ulcer- 
ate, and  the  cancerous  mass  will  spread  to  the  outside,  forming  fun- 

*  Rindfleisch,  loc.  cit.,  p.  351.  Curling,  Pitha,  Focrster,  Verneuil,  and  others,  admit 
scirrhus. 

t  "Archives  Gen.,"  February,  1879,  p.  129. 


CANCER.  417 

giis  hematodes,  the  true  cancerous  fungus.  This  is  bathed  in  a  thin 
bloody  ichor,  grows  rapidly,  portions  of  it  slough  away,  and  it  often 
bleeds  profusely.  Meantime  the  general  healtii,  perfect  at  first,  suffers 
proportionately  with  the  advance  of  the  disease,  until  finally  well- 
marked  cancerous  cachexia  is  reached,  attended  by  its  usual  sallow- 
ness  and  tendency  to  waste  away. 

The  pain  so  characteristic  of  this  disease  is  sometimes  very  slight 
in  the  testicle,  but  particularly  so  in  connection  with  the  cancerous 
growths  from  the  pelvic  and  lumbar  glands,  where  there  may  be  no 
pain  at  all  with  advanced  disease  (Brodie). 

Pathology. — The  disease  commences  at  different  points,  which  co- 
alesce. It  is  rarely  a  general  infiltration.  On  section  it  is  impossible 
with  the  naked  eye  to  distinguish  between  soft  carcinoma  and  soft 
sarcoma,  but  the  soft  ''medullary"  sarcoma  is  also  malignant,  affects 
the  retro-peritoneal  glands,  and  is  finally  fatal.  They  both  exhibit  the 
same  soft  spots,  perhaps  filled  with  pultaceous  matter,  the  same  white 
or  pink-white  colors.  The  microscope  shows  the  cancer  to  be  a  stroma, 
richly  permeated  by  young  cells,  inclosing  "  epitheloid  cell-aggrega- 
tions" which  owe  their  origin  (Birch — Hirschfeld)  to  the  proliferation 
of  epithelial  cells  of  the  glandular  tubuli  ;  the  medullary  sarcoma, 
also  malignant,  shows  a  broad  trabecular  work  of  sj)indle-shaped  cells, 
with  often  nests  of  epithelial  cells,  showing  that  it  is  partly  carcino- 
matous, or  a  round-celled  stroma,  with  elements  of  other  histoid  for- 
mations (mucous  cartilaginous  tissue,  Eindfleisch).  The  large  soft 
spaces  yield  a  plentiful  juice  when  pressed,  and  if  water  be  run  over 
them  the  softer  parts  may  be  washed  away,  leaving  a  delicate  stroma 
behind.  The  stroma,  again,  may  be  thickened  and  fibrous.  Cysts 
are  not  infrequently  found,  sometimes  blood-cysts,  or  large  blood-clots, 
as  in  kidney-cancer. 

Cancerous  degeneration  may  have  attacked  a  testicle  already  sar- 
comatous, when  we  should  find,  besides  the  conditions  above  described, 
perhaps  cartilage  more  or  less  calcified,  or  mucous  tissue,  or  unstriped 
muscle. 

The  enlarged  abdominal  glands  press  upon  the  vena  cava.  The 
cavity  of  the  latter  has  been  found  obliterated,  filled  with  cancer- 
growth  ;  the  bones  of  the  spine  become  involved,  while  secondary  can- 
cer may  be  found  in  the  kidneys,  liver,  and  lungs.  A  few  instances 
have  been  cited  of  cancer  of  the  testicle  beginning  in  the  tunica  vagi- 
nalis. One  or  two  cases  of  colloid  and  melanotic  cancer  are  recorded, 
as  well  as  a  few  of  scirrhus. 

Diagnosis. — In  the  early  stages  of  the  disease,  especially  if  its 
course  be  slow,  diagnosis  is  often  exceedingly  difficult.  The  diagnosis 
IS  with  sarcoma,  syphilis,  tubercle  (for  which  see  Diagxostic  Table), 
hydrocele,  and  haematocele,  with  dense  walls.  Hydrocele  or  ha?mato- 
cele  may  be  diagnosed,  if  all  other  symptoms  fail,  by  exploratory  punct- 
27 


418  DISEASES  OF  THE  TESTICLE. 

ure  with  trocar.  If  a  trocar  be  used  and  thrust  into  a  soft  part  of  a 
carciuomatous  testicle,  enough  blood  may  escape  to  encourage  the 
idea  of  hfematocele,  but  it  will  be  noticed  that  the  volume  of  the 
tumor  docs  not  decrease  proportionally  to  the  amount  of  blood  which 
has  escaped. 

Pro(/nosis  is  even  worse  than  for  cancer  elsewhere.  Two  years 
is  a  fair  average  duration  for  the  disease,  and  the  liability  for  second- 
ary cancer  to  appear  in  the  loins  or  elsewhere  after  operation  is  very 
great.  But  few  cases  are  reported  of  a  continuance  of  health  a  num- 
ber of  years  after  extirpation,  and  in  these  cases  the  operation  was 
always  done  very  early.* 

Treatment. — ]\Iedicine  is  of  no  service.  Puncture  of  tunica  vagi- 
nalis will  often  relieve  pain  immediately,  A  very  early  operation  offers 
the  only  chance,  but  ho2)e  departs  when  the  cord  and  glands  become 
involved. 

LYMPHADENOMA   OF   THE   TESTICLE. 

This  malady  has  been  carefully  described  by  Monod  and  Terrillon. 
Malassez  first  recognized  the  affection  in  a  specimen  sent  by  Pean  to 
the  laboratory  of  tlie  College  of  France  in  1874.  There  is  a  develop- 
ment of  tissue  similar  to  that  of  normal  lymphatic  glandular  tissue  as 
a  reticulated  stroma  occupying  the  tissue  between  the  tubes  in  the  testis 
and  destroying  them.  The  whole  extent  of  the  testicle  seems  to  be 
involved  from  the  beginning,  and  the  disease  may  simultaneously 
attack  both  glands,  a  peculiarity  not  noticed  with  other  neoplasms  in 
this  region.  Generalization  is  rapid  and  early  in  the  bones,  viscera, 
and  even  in  the  skin  and  subcutaneous  tissue,  at  a  distance  from  the 
primary  seat  of  disease.  General  cachexia  is  slow  to  come  on.  There 
is  no  leucocythemia.  Prognosis  is  fatal.  Eemoval  of  the  testicle  does 
no  good. 

SAHCOMA. 

Cystic  Sarcoma,  Enchoxdroma,  Myoma,  Myxoma. — This  affec- 
tion is  even  more  rare  than  cancer.  Its  cause  is  unknown.  It  occurs 
most  frequently  between  eighteen  and  twenty-five.  It  is  rarely  bilat- 
eral. The  body  of  the  testis  is  involved,  the  epididymis  sometimes 
secondarily.  When  the  morbid  mass  is  made  up  largely  of  cysts,  it 
is  called  cystic  sarcoma  ;  when  there  are  but  few  cysts  and  much  solid 
matter,  it  has  been  customary  to  call  it  fibro-cystic  sarcoma. 

SymptomH. — The  growth  of  sarcoma  is  slow  and  usually  painless, 
so  that  considerable  size  may  be  attained  before  the  disease  is  noticed. 
There  may  exceptionally  be  some  pain  or  dragging  in  loin,  groin,  or 
testicle,  especially  after  the  mass  has  become  bulky.     The  tumor  may 

*  Poinsot  cites  some  interesting  cases  of  apparent  cure  after  castration.    "  Bull,  de  la 
Soc.  de  Chir.,"  1878,  iv,  No.  3,  p.  169. 


SARCOMA.  41 9 

fittain  a  weight  of  several  pounds.  The  shape  is  oval,  and  the  surface 
smooth,  unless  some  large-sized  cysts  happen  to  he  superficial.  A 
healthy  epididymis  can  be  felt  at  first  distinct  from  the  testicle  ;  finally 
it  is  lost  in  the  general  swelling.  The  tumor  may  remain  many  years 
of  a  certain  size,  and  then  take  on  malignant  degeneration,  after  which 
symptoms  of  cancer  supervene. 

Sarcoma  is  liable  to  be  confounded  with  cancer,  tubercle,  syphilis 
(see  Diagnostic  Table),  hydrocele,  or  haematocle,  but  the  tumor 
is  elastic,  not  fluctuating,  and  a  trocar  distinguishes  it  from  the 
latter  affections.  Severe  pressure  often  produces  a  sensation  of  faint- 
ness. 

Patliology. — On  section  the  tunica  vaginalis  and  tunica  albuginea 
are  found  thickened.  There  may  be  but  a  few  cysts,  or  vast  numbers 
constituting  nearly  the  entire  tumor,  varying  in  size  from  a  point  to  a 
pigeon's  Qgg.  The  smaller  cysts  contain  a  gelatinous  fluid  which  gets 
thinner  afterward,  and  may  contain  cholesterin,  fatty  debris,  etc. 
The  fluid  is  often  colored  with  blood.  A  pure  watery  serum  is  rare. 
Sometimes  the  fluid  is  synovial-like,  sticky,  stringy.  The  cyst-walls, 
especially  the  smaller,  are  lined  by  cylindrical  epithelium.  Papillary 
excrescences,  covered  also  by  cylindrical  epithelium,  are  found  growing 
into  the  larger  cysts,  which  often  become  entirely  filled  up  by  them, 
as  in  cystic  sarcoma  of  the  breast,  and  as  in  the  latter  disease,  so  also 
in  this,  it  is  not  uncommon  to  find  in  the  cysts  little  yellow,  hard 
spherules  of  condensed  epithelium.*  As  to  the  mass  of  the  tumor, 
fibrous  tissue  is  found  in  greater  or  less  proportion,  and  as  the  tumor 
is  nearly  always  a  complicated  one,  it  is  not  unusual  to  discover  por- 
tions of  muscular  tissue  (of  both  kinds,  Senftleben,  Billroth,  Nepveu), 
masses  of  mucous  and  even  of  adipose  tissue,  and  hyaline  cartilage, 
perhaps  partly  calcified.  This  cartilage,  which  may  be  found  in  all 
sorts  of  curious,  branched  shapes,  has  been  made  out  by  Paget  and 
Billroth  to  occupy  the  lymph- vessels.  In  Paget's  case  the  cartilage 
extended  up  the  lymphatics  of  the  cord  into  the  abdomen,  and  a  mass 
was  found  growing  from  one  of  them  into  the  vena  cava.  Cartilag- 
inous nodules  were  found  in  the  lungs.  Where  there  is  much  carti- 
lage there  are  seldom  many  cysts.  Indeed,  the  tumor  may  consist 
solely  of  hyaline  cartilage  at  first.  This  grows  slowly,  painlessly,  and 
may  attain  the  size  of  a  hen's  egg,  when,  possibly  after  several  years, 
a  sudden,  rapid  enlargement  of  the  testis  sets  in,  and  we  find  that  the 
cartilage  has  become  surrounded  by  recently  formed  masses  of  sarcom- 
atous character.  Cretification  may  be  found  in  the  testicle  and  its 
coverings,  in  connection  with  enchondroma  or  sarcoma  (Eindfleisch). 

A  pure  myoma  may  occur  in  the  testicle  as  a  solid,  painless  lump. 
Rokitansky  describes  one  as  large  as  a  goose-egg,  of  striped  muscular 

*  These  little  pearl-like  clusters  of  epithelium  are  encountered  in  various  pathological 
conditions  of  the  testis. 


420 


DISEASES  OF  THE   TESTICLE. 


tissue  ;  Rindfleiscli  auothor,  of  unstripcd  fibers.  Sarcomu  miiy  occupy 
only  a  portion  of  the  testis  or  the  whole  gland  ;  the  tubular  structure 
is  then  either  found  spread  out  upon  the  new  de})osit  or  scattered 
through  it.  It  eventually  atrophies.  The  e])ididyinis  becomes  flat- 
tened and  wasted,  or  finally  involved  in  the  disease.  According  to 
Billroth,  sarcoma  commences  in  the  sub-epitlielial  tissues  of  the  semi- 
nal tubuli  as  a  round-celled  degeneration  of  the  tunica  propria,  leading 
to  occlusion  of  the  tubule  and  subsequent  dilatation  behind  the  oc- 
cluded point.  Commencing  cancerous  transformation  may  often  be 
detected. 

Treatment. — The  only  treatment  is  extirpation.  The  disease  may 
be  indeed  purely  benign  at  first,  and  remain  so  jierhaps  indefinitely, 
but  it  may  become  cancerous,  and,  if  the  individual  have  one  good 
testicle  left,  it  is  unwise  to  put  off  the  operation.  If  the  patient  be  a 
monorchid,  strict  justice  would  allow  delay  so  long  as  any  of  the  se- 
creting structure  of  the  testis  had  been  spared  by  the  disease  and  con- 
tinued its  functions. 

Lipoma  of  the  testicle  has  also  been  recorded  by  Roswell  Park,*  of 
Buffalo,  who  removed  such  a  tumor  growing  from  the  testis  and  filling 
the  tunica  vaginalis.     The  tumor  weighed  six  pounds. 


DIAGNOSTIC    TABLE. 

Since  it  is  so  diiScult  often  to  decide  upon  the  nature  of  a  given 
chronic  enlargement  of  the  testicle,  it  seems  advisable  to  display  the 
main  diagnostic  features  of  the  four  affections,  tubercular  testis,  syjihi- 
litic  testis,  cancer,  and  sarcoma,  side  by  side  in  tabular  form,  so  as  to 
bring  out  as  clearly  as  possible,  and  emphasize,  their  most  striking 
differences  : 


Tubercular  Tcxds. 

1.  Most  common 
in  early  youth  and 
manhood. 

2.  No  change  in 
scrotal  veins. 


3.  Docs  not  grow 
to  great  size. 

4.  Holds      second 
place  of  frequency. 


Sjipldlitic  Tcstvi. 

1.  ^fost  common 
in  middle  and  later 
life. 

2.  Same. 


3.  Is  usually  com- 
paratively small. 

4.  Most    common 
of  the  four. 


Cancer.  Sarcoma. 

1.    Most    common         1.    Most    common 
in  youth.  in  early  manhood. 


2.  Scrotal  veins  en- 
larged and  varicose 
after  the  disease  has 
lasted  some  time ; 
due  to  the  pressure 
of  cancerous  glands 
above. 

3.  May  reach  an 
immense  size. 

4.  Holds  third 
place. 


2.  No  change. 


3.  May      become 
very  large. 

4.  Least  common. 


*  "Medical  Record,"  May  8,  1886,  p.  542. 


DIAGNOSTIC   TABLE. 


421 


Tubercular  Testis. 

Si/philitic  TchHs. 

Cancer. 

Sarcoma, 

5.  Primarily  affects 

5.  Primarily  afTects 

5.  Same. 

5.  Same. 

epididymis. 

body  of  testiy. 

6.  Form  knotty,  ir- 

6. May  be  perfect- 

6. Uneven ;  prom- 

6. Slightly  uneven, 

regular,  hard,  espe- 

ly smooth  and  oval,  or 

inent  hard  and  soft 

oval,   perhaps    with 

cially  the  epididymis. 

more  or  less  lumpy. 

spots ;  indefinite  fluc- 
tuation. 

points  of  fluctuation. 

1.       Development 

v.  Same. 

7.       Development 

7.  Very   slow,  of- 

slow. 

rapid. 

ten  suddenly  becom- 
ing rapid. 

8.  Pain  absent  or 

8.  Often  absolute- 

8.  Pain  liable  to 

8.  No  pain. 

9.   Often     discov- 
ered by  accident. 


9.  Same. 


10.  Usually  no  sen-        10.  Same, 
sation   on    pressure, 
neither  pain  nor  the 
normal  sensation. 


11.  Fluid  in  tunica 
vaginalis  sometimes. 

12.  Tendency  to 
suppurate,  discharge, 
and  leave  fistula. 


13.  Both  testes  of- 
ten consecutively  at- 
tacked. 

14.  Loss  or  impair- 
ment of  sexual  de- 
sire and  power  when 
both  glands  are  in- 
volved. 

15.  Fungus  not 
very  common.  If 
found,  it  is  pale  and 
soft,  bleeding  rather 
easily,  composed 
mainly  of  granula- 
tions. Pus  thin,  si- 
nuses leading  into 
testicle,  growth  slow, 
usually  painless. 

16.  No  glandular 
enlars-ement. 


11.  Fluid  in  tunica 
vaginalis  nearly  al- 
ways. 

12.  Tendency  to 
atrophy  without  ex- 
ternal opening,  some- 
times there  are  a  dis- 
charge and  fungus. 

13.  Same. 


14.  Same,  and 
more  marked ;  some- 
times exists  when 
one  gland  only  is  dis- 
eased. 

1 5.  Fungus  very 
rare.  If  found,  it  is 
hard,  yellow,  mainly 
composed  of  tubes 
and  yellow  syphilitic 
matter,  does  not 
bleed  very  easily,  no 
sinuses,  growth  slow, 
painless. 

16.  Same. 


be  severe  soon  af- 
ter commencement, 
sometimes  excruciat- 
ing. 

9.  Recognized  by 
pains  from  the  start. 

10.  Darting,  sharp, 
burning  paroxysms 
and  constant  pains, 
aggravated  by  han- 
dling. 

11.  Fluid  in  tuni- 
ca vaginalis  usually 
slight. 

12.  Tendency  to 
open  and  form  fun- 
gus hsematodes. 


13.  Usually  only 
one  testicle  suffers. 

14.  Both  glands 
not  involved  simul- 
taneously. 


15.  Fungus  con- 
stant if  testis  remains 
long  enough,  grows 
rapidly,  bleeds  pro- 
fusely, sloughs  read- 
ily, is  covered  with 
sanious,  badly  smell- 
ing ichor,  is  formed 
mainly  of  cancer-tis- 
sue, is  very  painful. 

16.  Inguinal  and 
pelvic  glands  in- 
volved. 


9.  Tumor  grows 
slowly,  and  is  usually 
discovered  small. 

10.  No  pain; 
squeezing  testicle  of- 
ten produces  feehng 
of  faintness. 

11.  Fluid  in  tunica 

vaginalis  rarely. 

1 2.  No  tendency 
to  open  or  to  form 
fungus. 


13.  Same. 


14.  Same. 


15.  No  fungus. 


16.  Glands    some- 
times involved. 


422 


DISEASES  OF  THE  TESTICLE. 


Thibercular  Testis. 

17.  Very  rebellious 
to  medical  treatment. 


18.  Cord  always 
affected  eventually. 

19.  Vcsicuhe  sem- 
inales  liable  to  be- 
come involved. 

20.  Foci  lumpy. 


21.  Duration, 
eral  years. 


sev- 


22.  Prognosis  not 
favorable.  Progress 
always  indolent,  en- 
tire cure  rare. 


Si/philitic  Testis. 

1 7.  If  taken  early, 
quickly  amenable  to 
treatment.  lu  any 
case  always  reduci- 
ble in  size,  by  intelli- 
gent medication,  to 
which  all  doubtful 
cases  should  be  sub- 
jected, to  give  them 
a  chance. 

18.  Cord  never  in- 
volved in  a  pure  case. 

19.  Nothing  of  the 
sort. 


Cancer. 

17.  Treatment  in- 
effective. If  cut  out, 
returns  elsewhere. 


18.  Cord    affected 
in  advanced  disease. 

19.  Nothing. 


Sarcoma. 

17.  Medical  treat- 
ment ineffective.  If 
cut  out,  disease  does 
not  necessarily  reap- 
pear ;  if  left,  can- 
cerous degenerations 
may  occur. 


18.  Cord  never  af- 
fected. 

19.  Nothing. 


Excessively        20.  Hard  and  soft.         20.  Elastic. 


20 
hard. 

21.  Duration,  sev- 
eral years  —  usually 
less  than  tubercle. 

22.  Prognosis 
good  ;  gets  well,  with 
functions  restored  if 
treated ;  atrophies  if 
not  treated. 


21.  Duration,   av-        21.  Duration,  many 
erage  two  years.  years. 


22.  Prognosis  bad ; 
kills  by  bleeding  or 
cachexia  if  not  re- 
moved ;  by  return  of 
the  disease  if  extir- 
pated. 


22.  Prognosis 

good.  Does  not  re- 
turn if  removed.  If 
left,  liable  to  become 
cancerous. 


CASTRATION. 

This  is  an  operation  not  very  often  required  since  sarcoeele  (as  any 
chronic  fleshy  enlargement  of  tlie  testis  used  to  be  called)  has  been 
more  closely  studied  and  better  understood.  Still,  there  are  occasions 
when  it  is  proper  to  remove  the  testicle.  The  operation  is  a  simple 
one,  and  is  best  performed  as  follows  :  The  pubes,  perinaeum,  and 
scrotum  are  first  shaved,  and  any  complication  in  the  way  of  hernia  is 
excluded  if  possible.     An  anaBsthetic  should  always  be  administered. 

An  incision  is  made,  commencing  a  little  below  the  external  abdom- 
inal  ring,  and  carried  to  the  bottom  of  the  scrotum  along  its  anterior 
aspect.  Even  if  such  a  length  of  incision  were  not  required  by  the 
size  of  the  gland  to  be  removed,  5'et  it  is  better  to  make  it  long,  so 
that  the  lower  angle  may  be  depending,  and  thus  to  allow  a  free  exit 
for  the  discharges.  The  spermatic  cord  is  next  exposed,  and,  if  it 
must  be  ligated  very  high  up,  it  is  better  at  once  to  put  a  ligature  of 
silkworm-gut  or  stout  catgut  around  it,  and  to  tie  the  whole  cord 
quickly  and  firmly.  If  enough  of  the  cord  is  left  to  be  seized,  it  may 
be  held  by  the  fingers  of  an  assistant,  but  care  must  be  taken  not  to 
let  it  slip,  or  it  will  disappear  within  the  inguinal  canal  and  a  great 
deal  of  haemorrhage  may  occur  before  it  can  be  recovered  by  dissection. 


CASTRATION— DERMOID   CYSTS.  423 

The  cord  being  cut,  the  testicle  is  to  be  turnefj  out  more  by  tearing 
tliiin  by  cutting.  An  oval  piece  of  skin  may  be  removed  with  it  if  it 
is  very  large,  and,  if  it  adheres  pretty  tightly,  care  may  ne  required  to 
prevent  wounding  the  urethra  or  the  other  testicle  during  the  dissec- 
tion. After  the  testicle  is  removed,  the  arteries  of  the  cord  (the  sper- 
matic, deferential,  and  the  cremasteric)  may  be  tied  separately  with 
catgut,  and  all  the  bleeding  points  in  the  scrotum  secured.  If  a  single 
ligature  has  been  used  for  the  whole  cord  tied  high  up,  the  individual 
vessels  need  not  be  ligated.  Pain,  however  (and  even  tetanus),  has 
been  said  to  be  produced  by  the  single  ligature  from  including  the 
nerves  of  the  cord  and  the  vas  deferens.  The  wound  should  not  be 
united  until  all  the  bleeding  points  have  been  secured.  There  are  few 
operations  in  surgery  which  are  so  liable  to  be  complicated  by  trouble- 
some bleeding  after  the  wound  is  closed.  This  is  due  to  the  laxity  of 
scrotal  tissue.  Drainage  and  antiseptic  dressings  insure  a  good  result. 
Healing  by  first  intention  along  the  whole  line  is  not  uncommonly 
attained. 

If  hernia  complicates  the  disease  of  the  testis,  it  is  better  to  take 
advantage  of  the  opportunity,  slit  up  the  sac,  and  operate  for  radical 
cure  by  suturing  the  pillars  of  the  ring  with  catgut  or  silkworm-gut. 
If  the  cord  should  slip  into  the  inguinal  canal  after  being  divided,  and 
before  its  arteries  have  been  secured,  and  if  it  can  not  be  hooked  down, 
the  tendon  of  the  external  oblique  must  be  cut  at  the  external  pillar 
of  the  ring,  and  the  dissection  continued  up  the  canal  until  the  cut 
end  is  reached  and  all  its  bleeding  points  secured.  Several  instances 
of  death  are  recorded  from  neglect  of  this  precaution.  If  hsemorrhage 
comes  on  after  the  wound  has  been  closed,  it  should  be  reopened  and 
the  bleeding  vessels  searched  for.  A  few  points  of  suture  are  neces- 
sary, otherwise  the  edges  of  the  wound  will  be  kept  gaping  by  the 
contractions  of  the  dartos.  Self-castration  has  often  been  resorted  to 
by  lunatics,  or  by  individuals,  usually  young  men,  laboring  under 
some  depression  brought  on  by  masturbation  or  other  abuse  of  the 
organs.  The  bleeding  is  always  excessive,  but,  in  the  cases  reported, 
has  usually  been  successfully  arrested,  or  ceased  spontaneously. 

DERMOID    CYSTS    OF    THE    TESTIS. 

The  testicle,  next  to  the  ovary,  is  the  most  favorite  site  for  the 
development  of  dermoid  cysts.  These  cysts  are  cavities  lined  by 
integument,  furnished  with  stunted  papillae,  sebaceous  and  hair  glands. 
Their  contents  are  a  sebaceous  matter  mixed  with  epithelium  and  rolls 
of  long  hair,  usually  reddish.  Besides  these  there  are  often  found 
fully-formed  teeth,  sometimes  in  great  numbers,  often  imbedded  in 
portions  of  bone,  bones  with  smaller  bones  articulated  to  them,  car- 
tilage, muscle,  nerve.     In  a  personal  case  a  portion  of  the  inferior 


424,  DISEASES  OF  THE  TESTICLE. 

maxillary  bone  with  some  molars  and  a  bicuspid  were  found.  The 
dermoid  cyst  may  be  within  or  outside  the  testis,  as  in  Velpeau's  * 
cusc.  These  are  the  cysts  sometimes  known  as  fetal  inclusions.  The 
cysts  are  jn-obably  always  congenital.  They  usually  grow  very  slowly 
at  first,  but. may  reach  an  inconvenient  size  in  time.  Generally  they 
become  very  large,  then  suddenly  begin  to  grow  rapidly  and  are  re- 
moved, or.  becoming  injured  by  a  blow,  they  inliame,  suppurate,  and 
discharge  their  contents,  remaining  listulous. 

The  only  treatment  is  removal  with  the  knife.  It  should  be  re- 
membered that  the  cyst  sometimes  lies  outside  the  testicle,  the  latter 
adhering  to  it.  The  gland  should  be  dissected  otf,  and  spared  if  pos- 
sible. 

D'Arcy  Power  *  says  that  only  ten  cases  have  been  \n\t  on  record 
during  the  past  two  hundred  years.  He  showed  a  specimen  at  the 
London  Pathological  Society.     Ue  is  evidently  wrong. 


IRRITABLiE    TESTIS. 

This  is  a  name  given  to  a  species  of  neuralgia  of  the  gland.  The 
whole  organ,  or  usually  a  particular  spot,  is  extraordinarily  sensitive  to 
the  lightest  touch  ;  contact  of  the  clothing  alone  is  sometimes  exqui- 
sitely painful.  In  the  recumbent  posture,  with  nothing  in  contact 
with  the  testicle,  the  pain  usually  disappears.  Sometimes  the  organ 
is  tense  and  engorged  ;  but  it  is  of  full  size,  and  seemingly  normal. 
Again,  it  may  be  decidedly  flabby,  the  scrotal  tissues  being  soft  and 
lax.  Irritable  testis  occurs  at  all  times,  from  early  puberty  to  late 
middle  life.  It  is  met  with  chiefly  in  old  bachelors  and  widowers. 
The  patient  otherwise  may  possess  robust  health,  sometimes  (especially 
with  flabby  testis)  he  is  ancemic,  nervous,  hypochondriacal,  and  dys- 
peptic. 

The  causes  of  irritable  testis  are  lack  of  use,  or  abuse,  of  the  sex- 
ual powers — perhaps  most  often  ungratified  sexual  desire.  Curling 
says,  "In  a  person  of  chaste  habits,  thus  affected,  I  was  informed 
that  the  morbid  sensibility  disappeared  on  marriage."  Temporary 
irritable  testis  may  be  produced  in  a  healthy  person,  at  any  time,  by 
prolonged  sexual  excitement  ungratified.  Masturbators  who  have 
suddenly  reformed,  and  recent  widowers,  and  those  who  have  abused 
their  sexual  powers  by  over-use,  are  all  liable  to  the  affection  under 
consideration. 

These  patients  are  usually  hypochondriacal,  look  upon  their  own 

*  "Gaz.  Med.  de  Paris,"  February  15,  1840.  Andrd,  "M6m.  de  I'Acad.  Royale  de 
Med.,"  vol.  iii.  Ollivder  (d'An^er.^),  "  M6m.  sur  la  Monstrositd  par  Inclusion,"  "  Archiv. 
Gen.,"  vol.  xv.  Vcmeuil,  "  Archiv.  Gen.,"  June,  1855,  who  has  collated  nine  cases  besides 
one  of  his  own. 

f  "  Lancet,"  October  23,  1886,  p.  775. 


NEURALGIA   OF  THE   TESTICLE.  425 

condition  as  a  pitiable  one,  and  ascribe  it  to  loss  of  seminal  fluid — per- 
haps to  nocturnal  emissions — to  neither  of  wliich  does  it  stand  in  any 
relation  of  effect.  They  often  demand  castration — a  demand  which 
should  be  acceded  to  on  no  account.  Curling  quotes  from  Romberg 
an  interesting  case  bearing  on  this  point  :  A  young  man  acquired  irri- 
table testis  after  becoming  engaged  to  be  married.  It  distressed  him 
so  seriously  that  he  demanded  extirpation  of  the  organ,  and  would 
not  yield  until  at  last  the  operation  was  reluctantly  performed.  Eight 
days  afterward  the  old  pain  returned  in  the  other  testicle.  This  being 
all  he  had  left,  the  patient  preferred  to  keep  it.  He  married,  and 
"very  soon  recovered  completely." 

Treatment. — Hygiene,  physical,  moral,  and  sexual,  is  the  proper 
treatment  for  irritable  testis.  As  local  means,  a  suspensory  bandage 
and  the  cold  douche  are  adjuncts.  Drugs  exert  no  specific  power  and 
can  not  be  relied  upon.  Marriage,  with  a  proper  sexual  hygiene,  is 
the  natural  antidote  to  any  irritability  of  the  sexual  apparatus. 

NEURALGIA    OF    THE    TESTICLE. 

An  extreme  degree  of  the  condition  just  detailed  constitutes  neu- 
ralgia of  the  testicle,  a  disease  which  sometimes  attains  horrible  inten- 
sity, and  assumes  the  tic-douloureux  type  in  paroxysms  at  irregular 
(occasionally  regular)  intervals.  The  pain  in  some  cases  is  constant, 
and  perhaps  quite  mild,  but  increased  by  walking  and  standing  so  as 
to  occasion  great  discomfort.  The  character  of  the  pain  is  acute, 
darting,  stabbing,  sometimes  dragging,  heavy.  The  cremaster  some- 
times contracts  spasmodically  during  the  paroxysm,  forcibly  retract- 
ing the  testicle,  and  a  cold  sweat,  with  nausea  and  vomiting,  is  not  a 
rare  accompaniment.  Between  the  paroxysms  the  testicle  is  often 
entirely  free  from  pain.  Handling  the  organ  is  liable  to  induce  a 
paroxysm.  The  testis,  sometimes  swollen  and  tense,  is  usually  unal- 
tered. There  is  no  febrile  action.  Neuralgia  is  usually  confined  to 
one  testicle,  unlike  irritability,  which  is  frequently  double.  Neu- 
ralgia must  not  be  confounded  with  the  sympathetic  pain  in  the  tes- 
tis, and  its  retraction  from  spasm  of  the  cremaster,  accompanying  cer- 
tain morbid  states  of  the  bladder,  ureter,  and  kidneys,  and  so  often 
seen  in  kidney-colic. 

The  cause  of  neuralgia  of  the  testis  is  sometimes  difficult  of  appre- 
ciation. It  is  often  due  to  the  same  general  influences  which  lead  to 
the  development  of  neuralgia  elsewhere  (gout,  syphilis,  malaria,  etc.). 
It  sometimes  follows  an  attack  of  orchitis.  It  has  been  vaguely  re- 
ferred to  the  spinal  cord,  deranged  digestion,  etc.  It  has  been  seen 
to  follow  injury  and  to  attend  a  small,  deep-seated,  purulent  collec- 
tion.    B.  Brodie  *  found  it  in  one  case  always  preceded  by  clay-col- 

*  "Medical  Gazette,"  vol.  xiii,  p.  621, 


42G  DISEASES  OF  THE  TESTICLE. 

orcd  evacuations  and  i)ain  in  the  back  of  the  lu'ad.  Tie  believed  the 
cause  in  this  case  was  situated  in  the  liver.  In  another  case,  he  found 
a  small  projection  on  the  epididymis,  which,  on  pressure,  gave  the 
sensation  of  touching  an  exposed  nerve  in  a  tooth.  This  latter  condi- 
tion I  have  encountered  a  number  of  times.  Keuralgia  of  the  testicle 
not  infrequently  is  due  to  irritative  iuUammatory  or  other  disease  of 
the  deep  urethra,  and  may  be  cured  by  removing  its  cause — by  deep 
urethral  nitrate-of-silver  instillations,  use  of  the  sound,  or  other 
means. 

In  neuralgia  of  the  testis  no  nerve-lesion  has  been  found.  Sexual 
hygiene  will  be  often  found  at  fault.  The  affection  may  last  for  years 
and  (possibly)  then  disappear  spontaneously. 

Treatment. — Neuralgia  depending  on  bladder,  urethral,  or  kidney 
disease,  disappears  with  its  cause.  In  true  neuralgia,  a  strict  h3'giene 
is  all-important ;  this  involves  marriage.  Among  drugs,  arsenic,  qui- 
nine, and  iron  bear  the  best  reputation  internally  ;  belladonna,  opium, 
and  aconite  externally.  But  little  reliance  can  be  placed  on  them, 
however ;  sexual  and  general  hygiene  outrank  all  remedies.  If  the 
testicle  be  extirpated,  there  is  always  danger  of  a  return  of  the  pain 
in  the  cord,  or  in  the  other  gland.  Diday  *  recently  very  strongly 
advocates  the  continued  application  of  cold  in  all  pure  cases  of  neu- 
ralgia, and  claims  remarkable  success  with  this  agent.  His  method 
consists  in  filling  two  bladders  with  large  pieces  of  ice.  One  of  these 
he  places  upon  towels,  so  arranged  as  to  underlie  and  support  the 
testis,  the  patient  being  supine.  The  other  bag  is  now  placed  upon 
the  testis,  so  that  the  whole  organ  is  surrounded  by  ice,  or,  rather, 
iced-water.  This  application  is  kept  up  night  and  day  for  two  to 
four  days,  after  which  (Diday  states)  the  neuralgia  does  not  return. 
William  A.  Hammond  f  claims  to  have  cured  this  malady  by  tightly 
squeezing  the  entire  cord  between  the  blades  of  an  instrument  like  a 
lemon-squeezer  for  five  minutes,  then  letting  up  the  pressure  (to  allow 
circulation  to  be  resumed)  and  reapplying  it.  I  have  not  tested  this 
method. 

*  "  Annales  de  Derm,  et  de  Syph.,"  1869,  No.  3,  p.  182. 
f  "  St.  Louis  Courier  of  Mcdiciue,"  May,  1880. 


IMPOTENCE.  427 


CHAPTEE  XXVI. 

MALADIES  INVOLVING   THE  GENITAL  FUNCTION. 

Impotence.— True  Impotence,  its  Causes  and  Treatment.— False  Impotence,  its  Causes  and  Treat- 
ment.—Sterility.— Masturbation.— Pollution,  Nocturnal  and  Diurnal.— Spermatorrhcea. — ^Eroto- 
mania.—Satyriasis.— Priapism.— Aspermatism. 

Impotence  is  a  symptom,  usually,  of  some  physical  morbid  condi- 
tion entailing  inability  to  accomplish  the  sexual  act.  Its  causes  are 
very  numerous.  Most  of  them  have  been  already  considered  ;  the 
others  will  receive  a  few  words  of  detail  in  this  chapter.  Impotence 
will  only  be  considered  as  affecting  the  male. 

Impotence,  from  whatever  cause,  is  a  complaint  not  unfrequently 
submitted  to  the  surgeon  ;  not  always  frankly  and  openly  as  such,  but 
often  by  implication,  as  though  it  should  be  recognized  and  inquired 
about,  in  answer  to  remote  indications  which  the  patient  has  scantily 
furnished.  Indeed,  the  surgeon  who  would  meet  the  daily  wants  of  his 
fellow-men,  in  reference  to  troubles  of  this  sort,  must  possess  an  accu- 
rate knowledge  of  the  physiology  of  the  sexual  function,  and  of  its  vari- 
ous derangements,  and  be  ready  to  anticipate  the  reticence  of  patients  ; 
otherwise  he  will  fail  to  sound  many  of  the  depths  of  human  nature, 
where  suffering  lurks — which  suffering  is  for  the  most  part  prevent- 
able or  relievable. 

Impotence  signifies  that  an  individual  can  not  beget  children  be- 
cause he  can  not  perform  the  sexual  act  properly,  no  matter  what  the 
obstacle  may  be,  whether  he  have  spermatozoa  or  not.  The  term  must 
be  carefully  distinguished  from  sterility,  which  signifies  inability  to 
beget  offspring  on  account  of  defect  in  the  semen,  whether  the  indi- 
vidual can  have  sexual  intercourse  properly  or  not.  The  two  are 
undoubtedly  often  associated  in  the  same  individual,  but  they  may  be 
totally  distinct,  as  the  following  examples  will  illustrate.  Thus  there 
are  two  methods  of  making  eunuchs  in  the  East  :  by  one  the  j^enis  is 
removed  as  well  as  the  testicles,  and  such  a  eunuch  is  necessarily  both 
impotent  and  sterile.  By  the  other  method  the  testicles  alone  are  re- 
moved ;  and  a  eunuch  of  this  description,  though  sterile  (having  no 
spermatozoa),  may  be  still  partly  potent,  and  does  not  bring  so  high 
a  price  as  another  eunuch  who  has  no  penis.  It  is  a  well-known  fact 
that  both  animals  and  men,  from  whom  the  testicles  have  been  re- 
moved after  puberty,  still  retain  sexual  desires,  *and  may  have  inter- 
course, with  venereal  orgasm  and  ejaculation  of  prostatic  mucus, 
occasionally  during  a  period  of  several  years.  A  cryptorchid  is  rarely 
at  all  impotent,  but  is  very  apt  to  be  sterile,  and  so  of  a  patient  with 


428  MALADIES  INVOLVING  THE  GENITAL  FUNCTION. 

double  gonorrhceal  epididymitis  ;  while,  as  instances  of  impotence  with- 
ont  any  sterility,  may  be  mentioned,  deformities  preventing  sexual 
intercourse,  where  the  spermatic  lluid  is  normal  (exstrophy  of  the 
bladder),  extreme  incurvation  of  the  penis,  with  or  without  hypospa- 
dias, asperniatism. 

The  distinction  between  impotence  and  sterility  being  now  plain,  a 
few  words  regarding  each  of  these  complaints  will  perhaps  serve  to 
clear  them  of  the  mists  of  uncertainty  which  often  surround  them. 

Impotence  may  be  considered  as  true  and  false. 

TRUE  IMPOTENCE. 

This  is  exceedingly  rare  in  the  male.  Any  one  who  can  perform  the 
sexual  act  is  potent.  This  act  imperatively  involves  two  conditions, 
namely,  sufficient  erection  to  make  intromission  possible,  and  a  mucous 
fluid  leaving  the  body  by  ejaculation.  Roubaud  *  has  added  two  other 
factors  as  essential  to  the  act  of  copulation  ;  namely,  the  existence  of 
venereal  desire  and  pleasure  in  the  act ;  and,  although  both  of  these 
undoubtedly  exist  in  a  state  of  health,  nevertheless  the  absence  of 
either  of  them  by  no  means  necessitates  impotence,  while  the  absence  of 
either  of  the  first-named  conditions  is  impotence.  An  illustration  of 
these  points  will  bring  out  all  that  can  be  said  practically  concerning 
true  impotence. 

That  lack  of  desire  before  the  act  and  j^leasure  during  its  accom- 
plishment are  not  absolute  essentials  to  sexual  intercourse  is  shown 
by  the  two  conditions,  priapism  from  cantharides,  in  which  there  is  no 
desire,  and  yet  intercourse  is  possible  with  perfect  intromission  and 
ejaculation,  and  certain  diseases  of  the  cord  attended  by  more  or  less 
paraplegia,  where  intercourse  may  take  place,  followed  by  conception, 
and  yet  there  be  no  pleasure  in  the  act  of  ejaculation,  the  patient  being 
unconscious  at  what  moment  it  occurs. 

CoxDiTiONS  iNVOLYixG  True  Impotexce  : 

1.  Absence  of  penis,  as  in  the  cases  already  referred  to  Q).  5).f 
In  these  cases,  if  there  are  healthy  testicles,  the  patient  can  not  be 
called  sterile. 

2.  Minute  size  of  penis  may  involve  impotence,  as  in  Roubaud's 
case  of  a  student  whose  penis  was  so  small  that,  although  he  could 
practice  masturbation,  he  was  not  able  to  reach  the  stage  of  ejaculation 
during  sexual  intercourse,  on  account  of  the  minute  size  of  his  penis, 
between  which  and  the  vaginal  walls  there  was  little  or  no  friction. 
Roubaud  J  rendered  this  man  potent,  and,  he  says,  greatly  increased 
the  size  of  his  i)enis  by  fitting  him  with  an  artificial  one,  into  a  depres- 

*  "De  rimpuissance  et  dc  la  Sterility,"  Paris,  1872,  second  edition, 
f  A  ca?e  has  been  encountered  by  the  author. 
X  Op.  cit.,  p.  160. 


TRUE  IMPOTENCE.  429 

sion  in  which  his  own  would  fit,  and  directing  a  series  of  copulative 
acts,  anointing  the  penis,  etc. 

That  small  size  is  only  relatively  a  cause  of  impotence  is  evident, 
and  that  it  by  no  means  involves  sterility  is  shown  by  Orfila,*  in  a 
case  where  an  action  for  rape  was  brouglit  against  a  man  with  only  the 
stump  of  a  glans  in  place  of  the  full  penis,  by  a  woman  who  was  im- 
pregnated by  him.  Orfila  decides  that  impregnation  may  take  place 
under  these  circumstances,  but  only  through  the  consent  of  the  woman, 
and  that  rape  is  consequently  impossible.  The  numerous  cases  on 
record  where  impregnation  has  taken  place  without  rupture  of  the  hy- 
men shows  that  a  deposit  of  semen  within  the  ostium  vaginae  may  fer- 
tilize an  ovum,  and  such  a  deposit  of  semen  might  be  accomplished  by 
the  smallest  possible  penis.  Intromission  and  ejaculation  might  take 
place,  and  impotence,  though  possible  (as  in  Eoubaud's  case),  is  not 
necessary.     The  patient  is  not  sterile. 

3.  Extreme  size  of  the  penis  is  a  (relative)  cause  of  impotence. 

4.  Extreme  ejjispadias  and  hypospadias,  with  or  without  extreme 
incurvation,  involve  impotence,  without  sterility.  Exstrophy  of  the 
bladder  the  same  ;  and,  although  as  in  Huguier's  f  case,  copulation 
might  be  possible  with  exstrophy,  yet  intromission  of  semen  would  not 
take  place,  and  impotence  would  be  inevitable.  The  female  with  ex- 
strophy is  neither  impotent  nor  sterile.  Slight  hypospadias  may,  but 
does  not  necessarily,  involve  impotence.  The  semen  is  not  properly 
ejaculated  into  the  upper  part  of  the  vagina,  and  impregnation  some- 
times fails  to  take  place — through  the  fault  of  the  male.  A  very  short 
frenum  may  act  in  the  same  way  as  slight  hypospadias. 

5.  Large  size  of  the  prepuce,  excessively  tight  and  narrow  orifice 
of  the  same,  may  involve  impotence,  as  may  also  any  tumors  or  growths 
upon  or  about  the  penis,  elephantiasis,  fatty  tumor,  hydrocele — or 
neighboring  deformity,  as  faulty  position  of  the  thigh  from  anchylosis 
of  hip,  excess  of  abdominal  fat,  etc.,  all  of  which  may  mechanically 
interfere  with  copulation  without  in  the  least  implying  sterility. 

6.  Very  tight  stricture  of  the  urethra,  esj)ecially  if  there  be  large 
and  multiple  fistulse  behind  it,  may  involve  impotence.  The  semen 
does  not  escape  by  ejaculation,  but  dribbles  away  after  erection  sub- 
sides. A  similar  cause  of  impotence  exists  in  a  vicious  direction  of 
the  orifices  of  the  ejaculatory  ducts,  by  which  the  semen,  during  ejacu- 
lation, is  turned  backward  into  the  bladder,  and  escapes  afterward 
with  the  urine,  as  in  Peyronie's  case,  J  or  from  prostatic  disease.  Ac- 
cording to  Grimaud  de  Caux,*  such  a  condition  of  things  may  be 
caused  by  the  action  of  a  certain  class  of  Parisian  prostitutes,  who, 

*  "Medecine  legale,"  vol.  i,  pp.  ITV,  ITS. 
t  "Gaz.  des  Hop.,"  1840,  p.  467. 

X  Quoted  by  Orfila,  "  Traite  de  Med.  legale,"  fourth  edition,  vol.  i,  p.  186. 

*  "  Physiologie  de  I'Espece,"  Paris,  1847,  p.  337. 


430  MALADIES  INVOLVING  THE  GENITAL  FUNCTION. 

fearing  pregnancy,  watch  for  the  moment  of  ejaculation,  and  then 
press  forcibly  upon  the  urethra  of  their  })artncr  just  in  front  of  tiie 
prostate,  by  inserting  a  linger  into  liis  rectum.  By  this  means  tlie 
veru  montanum,  the  natural  dam  to  prevent  reflux  of  semen  into  the 
bladder,  is' forcibly  turned  backAvard,  and  finally,  by  a  rojietition  of 
the  act,  the  faulty  direction  of  the  senien  becomes  permanent,  and 
the  individual  remains  impotent,  ejaculating  his  semen  into  his  own 
bladder. 

7.  The  peculiar  affection  called  aspermatism  is  impotence.  The 
patient  is  not  sterile  ;  his  copulation  is  jicrfect,  except  ejaculation. 

8.  Imperfect,  irregular,  bent  erections,  due  to  intlammution  of  or 
deposits  of  various  kinds  in  the  sheaths  or  substance  of  one  of  the 
erectile  cylinders  of  the  penis,  may  sometimes  be  extreme  enough  to 
prevent  intromission,  and  entail  imi)otence. 

9.  Eunuchs,  and  patients  having  atrophy  of  both  testicles,  are  usu- 
ally impotent,  always  sterile. 

10.  Planque  mentions  a  case  where  a  blow  on  the  head  was  followed 
by  permanent  loss  of  erection.  The  same  may  follow  jirolonged  sper- 
matorrhoea, or  excessive  and  continued  masturbation. 

11.  Impotence  may  be  symptomatic — not  to  speak  of  the  physio- 
logical impotence  of  childhood  and  old  age — and  then  is  only  condi- 
tional or  temi3orar3%  and  disappears  usually  with  the  removal  of  the 
cause.  Impotence  depending  upon  most  of  the  conditions  already  enu- 
merated is,  critically  speaking,  symj3tomatic,  such  as  impotence  from 
local  deformity  or  overgi'owth,  or  obesity,  or  stricture  ;  but  the  term 
"  symptomatic  "  is  used  to  make  a  class  apart  from  idiopathic  impo- 
tence, in  both  of  which  the  entire  sexual  tract  and  the  penis  are  seem- 
ingly in  good  condition.  A  single  example  will  illustrate  the  point : 
A  has  double  syphilitic  orchitis  ;  has  no  desire,  no  erections — has,  in 
short,  impotence  symptomatic  of  syphilis.  Prompt  treatment  is  em- 
ployed ;  his  testicles  return  to  a  normal  state,  his  erections  reappear, 
and  he  is  well.  B  has  the  same  condition  of  the  testicles,  the  same 
impotence,  but  he  employs  no  treatment ;  both  testicles  go  on  to  atro- 
phy, and  he  passes  from  a  condition  of  symptomatic  into  one  of  true 
impotence,  with  sterility  as  well. 

In  symptomatic  impotence  there  is  always  lack  of  erection,  and 
often  also  temporary  sterility.  Under  the  head  of  impotence  symp- 
tomatic of  intoxication,  Roubaud  mentions,  as  causes,  hashish,  cam- 
phor, iodine,  antimony,  arsenic,  lead  ;  and,  although  some  of  these  have 
some  influence  over  the  sexual  function,  it  is  well  not  to  overestimate 
their  power.  The  supposed  efficiency  of  iodine  in  producing  atrophy 
of  the  testicle  is  largely  hypothetical,  and  evidently  based,  to  a  great 
extent,  upon  the  influence  of  Iodine  over  syphilitic  enlargement  of  the 
testicle,  and  the  coincidence  of  atrophy  of  the  same  after  an  inefficient 
course  of  iodine. 


FALSE   IMPOTENCE.  431 

Symptomatic  imiootence,  broadly  considered,  is  found  in  connection 
with  all  acute  (general)  febrile  diseases,  more  or  less  marked  with  all 
cachexioG,  in  connection  witli  any  advanced  condition  of  disease  of  the 
testicle,  especially  with  syphilitic  testis,  often  depending  on  syphilis, 
without  any  appreciable  affection  of  the  testicle.  It  is  encountered 
with  severe  varicocele  and  neuralgia  of  the  testis,  with  bad  cases  of 
spermatorrhoea,  and  as  a  result  of  the  lack  of  tone  of  the  genitals  pro- 
duced by  long-continued  excess — especially  by  masturbation — with 
severe  diabetes  and  other  advanced  devitalizing  diseases.  Roubaud 
relates  an  exceedingly  interesting  case  of  symptomatic  impotence,  where 
a  patient  ap]3lied  to  him  with  large  double  hydrocele,  and  was  entirely 
impotent.  Eoubaud  supposed  that  the  continued  pressure  of  the  hy- 
droceles had  caused  atrophy  of  the  testes.  He  punctured  on  both  sides. 
The  patient  recovered  his  potence,  and  impregnated  his  wife.  He  lost 
power  again  when  the  sacs  refilled.     The  testicles  were  not  atrophied. 

13.  Finally,  impotence  may  come  on  without  assignable  cause  ;  but 
there  are  certain  well-recognized  causes  which,  acting  upon  certain 
subjects,  are  capable  of  producing  impotence,  more  or  less  prolonged. 
Partial  erection,  attended  by  rapid  ejaculation,  is  a  not  uncommon 
variety  of  impotence,  due  usually  to  continence,  overexcitement,  etc., 
and  observed  in  animals  as  well  as  in  men.  In  such  cases  also  there 
will  be  found,  not  infrequently,  a  neuralgic  condition  of  the  prostatic 
sinus,  and  the  treatment  usually  most  effective  is  that  of  neuralgia 
of  the  vesical  neck,  with  instillations  of  nitrate  of  silver,  the  cold 
sound,  local  external  applications  of  cold  water,  and  general  hygienic 
measures.  These  means,  aided  by  the  confidence  with  which  a  phy- 
sician should  inspire  his  patient,  and  the  counsel  to  be  deliberate  in 
the  sexual  act,  and  to  practice  it  in  the  early  morning  rather  than  the 
evening  ;  or  even  to  trust  to  a  second  effort,  rather  than  place  all  hope 
upon  the  first,  will  often  overcome  this  variety  of  impotence  in  time. 
Circumcision  may  sometimes  be  necessary  to  diminish  the  sensitive- 
ness of  the  glans  penis,  which  is  often  overacute. 

FALSE    IMPOTENCE. 

False  impotence  is  an  affection  which  the  practical  physician  is 
often  called  upon  to  treat.  True  impotence  involves  the  treatment  of 
the  physical  irregularity,  deformity,  disease,  cachexia,  etc.,  giving 
rise  to  it.  False  impotence  requires  a  treatment  of  the  individual, 
and  not  of  any  disease.  In  false  impotence  the  cause  is  always  nerv- 
ous, or,  it  may  be,  a  moral  one ;  and  there  is  often  no  impotence  at 
all,  except  in  the  mind  of  the  individual.  Here  the  surgeon  requires 
all  his  delicacy,  all  his  sympathy,  in  order  to  obtain  the  confidence  of 
his  patient,  overcome  his  suspicions,  and  gently  lead  him  to  a  cure, 
which  is  always  possible  if  only  the  patient  have  faith. 


432  MALADIES   I.WOLVING   THE   GEXITAL  FUNCTION. 

Among  the  causes  of  false  impotence  may  be  mentioned  sexual  in- 
difference, either  temporary  and  spontaneous  or  more  or  less  prolonged, 
as  a  result  of  sudden  shock,  grief,  excessive  joy,  fright,  repugnance, 
lack  of  affection  for  the  individual  with  wliom  copulation  is  attempted. 
Under  the  two  latter  circumstances,  the  patient  will  sometimes  think 
of  another  i)er.>on  tlian  the  one  with  whom  he  is  lying,  and  thus  main- 
tain erection  and  effect  ejaculation.  The  sudden  flooding  of  the 
vagina  with  warm  mucus  will  sometimes  cause  erection  to  cease  at 
once.  Drunkenness  Avhicli  is  not  habitual  may  induce  temjiorary 
impotence.  Koubaud  mentions  a  curious  case  where  impotence  came 
on  with  an  indigestion,  and  remained  long  after  its  cause  had  disap- 
peared. He  speaks  *  of  anotlier  man  who  became  imjDotent  on  draw- 
ing a  ])rize  of  thirty  thousand  francs  in  a  lottery. 

Another  curious  case  of  false  impotence  is  related  by  the  same 
author  :  f  A  young  man  brought  up  in  the  country  was,  at  the  age  of 
fourteen,  initiated  into  the  mysteries  of  Venus  by  a  young  friend  of 
the  family,  twenty-one  years  old.  Her  hair  was  liglit,  and  worn  in 
curls,  and,  for  precaution's  sake,  she  never  had  intercourse  with  the 
boy  except  when  dressed — that  is,  wearing  a  corset,  high  boots,  and  a 
silk  dress.  The  boy  yielded  for  the  sake  of  pleasure,  but  had  no  affec- 
tion for  the  ]ii(\y.  She  was  passionate,  and  drev/  largely  upon  his 
young  powers  during  four  years,  after  which  he  went  to  the  military 
school.  On  entering  garrison,  he  found  that  he  had  full  sexual 
powers,  but  that  they  were  aroused  only  by  certain  women,  and  under 
certain  circumstances.  A  dark  beauty  had  no  power  over  him,  and  a 
night-dress  extinguished  all  his  fire.  In  short,  he  found  himself 
utterly  impotent  except  in  the  comjoany  of  a  light-haired  woman, 
wearing  curls,  with  high  boots,  a  corset,  and  a  silk  dress. 

This  false  impotence  had  a  powerful  hold  over  him.  Twenty-five 
years  after  having  left  his  seducer  it  was  still  upon  him,  and  that,  too, 
in  spite  of  his  having  meantime  fallen  desperately  in  love  with  a  bru- 
nette, to  whom  he  was  afraid  to  offer  himself  on  account  of  his  inca- 
pacity ''d'exercer  le  coit  dans  le  neglige  de  la  couche  conjugale." 

In  this  case,  the  exercise  of  tact,  aided  by  an  aphrodisiac  potion  of 
cantharides  and  phosphorus  in  time  effected  a  complete  cure. 

An  equally  instructive  case,  illustrative  of  false  impotence,  occur- 
ring in  the  practice  of  Peirilhe,  is  related  by  Grimaud  de  Caux,;]:  of  a 
celebrated  mathematician,  who  married  a  young  and  beautiful  woman, 
whom  he  loved  tenderly.  He  felt  the  power  of  her  charms,  and  could 
commence  the  sexual  act  creditably,  but,  althougii  they  both  ardently 
desired  a  child,  before  the  moment  of  ejaculation  arrived,  the  thoughts 
of  the  philosopher  would  unconsciously  stray  toward  some  favorite  and 
engrossing  mathematical  problem,  and  erection  would  fail.  A  cure — 
at  least  to  the  extent  of  making  Mr.  father  to  several  fine  cliil- 


Op.  cit.,  p.  186.  t  Op.  cit.,  p.  439.  t  Op.  ciL,  p.  341. 


FALSE   IMPOTENCE— TREATMENT.  433 

drcn — was  effected  by  instructing  his  wife  to  get  her  husband  partially 
intoxicated  before  accepting  his  approaches — the  success  of  the  expe- 
dient establishing  the  truth  of  the  old  adage  : 

"  Sine  Ccrere  et  Baccho  friget  Venus.'' 

Treatment. — This  form  of  moral  impotence  requires  special  atten- 
tion to  all  the  agencies  which  may  be  active  as  causes,  and  the  exer- 
cise of  patient  tact,  and  often  of  sympathy  to  acquire  and  retain  the 
patient's  confidence,  a  point  of  treatment  most  essential  to  success. 
The  surrounding  hygienic  conditions  must  be  made  favorable,  the 
advantages  derived  from  change  employed,  all  indications  of  deviation 
from  health  in  any  respect  appropriately  met.  It  is  necessary  to  arouse 
the  moral  sentiment  of  carnal  desire,  as  well  as  the  power  of  the  organs, 
locally,  to  respond.  The  first  is  attained  by  favorable  relations  to  the 
sex — opera,  theatre,  etc.  The  second,  by  general  dry  frictions  of  the 
whole  body,  by  massage  and  flesh-brush  ;  cold-bath  ;  sea-bathing ; 
generous  diet,  and  the  internal  use  of  tonic  medication ;  the  mineral 
acids,  strychnine,  ergot,  and  esjoecially  phosphorus  and  cantharides, 
or  the  two  combined,  commencing  at  a  fair  dose,  one-fortieth  of  a 
grain  of  the  former  to  ten  drops  of  the  tincture  of  the  latter,  three  or 
four  hours  before  the  desired  erection,  and  increasing  the  dose  care- 
fully. Cantharides  produces  erection  without  desire  ;  phosphorus  and 
damiana  increase  desire  directly.  Cold  and  heat,  by  the  douche,  elec- 
tricity, and  local  applications  of  mustard,  are  sometimes  serviceable  in 
recalling  erection.  In  one  case  of  syphilitic  impotence,  decided  ad- 
vantage was  derived  from  the  use  of  a  quack-treatment,  by  an  instru- 
ment called  the  equalizer,  a  large  cell,  in  which  the  patient  sits  with 
his  head  out,  and  from  which  the  air  is  exhausted.  (A  modification 
of  the  ventouse  enorme  of  the  French.) 

Nervous  impotence,  the  most  common  form  of  false  impotence, 
encountered  frequently  in  young  men,  remains  yet  to  be  described. 
The  patient  is  young  and  usually  healthy.  He  has  generally  mastur- 
bated more  or  less,  and  has  nocturnal  pollutions.  He  has  usually 
plentiful  evidences  of  virile  power.  He  has  desires  which  are  some- 
times excessive.  He  awakes  with  erections.  He  can  provoke  erection, 
or  even  emission,  at  will  ;  but,  in  presence  of  a  woman,  and  when 
he  desires  to  have  sexual  intercourse,  his  organs  will  not  respond  ;  or, 
if  erection  comes  on,  it  lacks  full  energy,  and  is  liable  to  fail  at  any 
moment  during  the  act.  In  short,  the  patient  can  do  anything  he 
wishes,  except  that  he  can  not  rely  upon  an  erection  at  the  critical 
moment. 

This  form  of  impotence  is  the  result  of  unnatural  excitement  of  the 
sexual  functions.  It  may  come  from  protracted  chastity,  ungratified 
desii'e,  or  excessive  erotic  excitement  at  the  moment.  It  is  not  infre- 
quently accompanied  by  involuntary  emissions  during  sleep,  and  by  the 

28 


434  MALADIES  INVOLVING  THE  GENITAL  FUNCTION. 

occasional  escape  from  the  urethra  at  any  time  of  a  semi-transparent, 
viscid  fluid  furuislied  by  the  uretlira  and  prostatic  follicles.  The  most 
persistent  and  obstinate  mental  dejection  usually  accompanies  this 
form  of  impotence.  Under  the  pressure  of  imperious  desire,  and  after 
prolonged  chastity,  the  sufferer  has  ])robably  approached  some  incon- 
gruous female,  and  at  the  portals  of  success  his  erection  has  failed  him. 
The  mental  depression  following  an  experience  of  this  sort  is  of  the 
most  exaggerated  nature,  the  existence  of  impotence  is  considered  as 
demonstrated  beyond  cavil,  and  hope  is  obstinately  banished  from  the 
liorizon.  The  seminal  fluid,  it  is  assumed,  is  escaping  in  the  urethral 
discharges,  and  with  it  manhood  and  vitality.  These  ideas  are  inten- 
sified by  the  cunningly  conceived  advertisements  of  charlatans,  with 
which  the  swarming  newspapers  abound,  and  the  patient  is  still  further 
enveloped  by  them  in  despair.  False  promises  of  cure  often  tempt  him 
to  a  trial,  and  their  failure  relegates  him  to  the  surgeon  sooner  or  later, 
more  than  ever  deeply  despondent.  Such  cases,  which  are  unhappily 
not  rare,  require  for  their  management  all  the  ability  and  tact  that 
can  be  brought  to  bear  upon  them. 

Treatment. — The  best  treatment  for  a  man  with  nervous  impotence 
(who  invariably  awakes  sooner  or  later  with  an  erection)  is  to  patiently 
instruct  him  in  sexual  physiology  and  hygiene,  acquire  his  confidence 
by  sympathy,  and  get  him  married,  with  the  advice  to  attempt  no  in- 
tercourse, to  be  entirely  frank  and  honest  with  his  wife  (who  will  more 
than  equal  him  in  timidity  and  ignorance),  and,  awaiting  some  morn- 
ing when  awaking  with  a  vigorous  erection,  to  accomplish  coitus 
promptly,  without  delay  or  dalliance,  as  a  matter  of  imperious  duty. 
The  act  once  accomplished,  the  charm  is  broken.  The  use  of  the 
steel  sound  and  of  local  applications  of  tannin,  with  the  cupped  sound, 
or  of  instillations  of  the  nitrate  of  silver,  often  of  decided  service  where 
ejaculation  is  too  rapid,  are  also  sometimes  useful  here. 

STERILITY. 

The  consideration  of  sterility  is  so  interwoven  with  that  of  impo- 
tence that  but  little  remains  to  be  said.  Sterility  is  an  inability  to 
beget  children  on  account  of  absence  or  imperfection  of  the  semen, 
and  in  many  such  cases  there  is  impotence  as  well.  All  eunuchs  are 
sterile  ;  when  both  testicles  are  degenerated  or  destroyed  by  disease  or 
atrophy,  or  retained  as  in  cryptorchids  (usually),  sterility  results.  In 
two  special  conditions  there  is  sterility  without  impotence,  namely, 
obliteration  of  the  canal  of  the  epididymis,  after  double  gonorrhceal 
epididymis,  and  obliteration  of  the  orifices  of  the  ejaculatory  ducts, 
after  stone  or  operations,  from  cauterization  of  the  prostatic  urethra 
with  solid  nitrate  of  silver,  after  the  process  of  Lallemand.  Of  the 
latter  we  see  and  hear  little  in  this  country  at  the  present  day,  but, 


SELF- ABUSE.  435 

according  to  Grimaud  de  Caux,  in  his  time  the  instrument  of  Lalle- 
mand  made  more  eunuchs  than  did  the  demands  of  the  harems  of  the 
East.  AVhenever  the  seminal  duct  is  occluded  on  both  sides  at  any 
part  of  its  course,  sterility  is  the  natural  result,  since  the  sjiermatozoa 
can  not  reach  the  urethra,  but,  under  these  circumstances,  if  the  testi- 
cles are  healthy,  the  patient  is  fully  potent,  his  desire,  his  erection,  his 
ejaculation,  his  pleasure,  are  normal ;  his  ejaculated  fluid  resembles 
semen  in  every  respect  except  that  it  contains  no  seminal  clement. 

The  relief  of  sterility  depends  uj)on  its  cause,  which  often  can  not 
be  directly  reached  by  treatment. 

SELF-ABUSE. 

Self-abuse  is  the  production  of  the  venereal  orgasm  upon  one's  self. 
The  term  masturbation  signifies  that  an  orgasm  is  produced  by  means 
of  friction  with  the  hand,  as  it  most  commonly  is.  Masturbation  is 
not  a  malady.  It  does  not  necessarily  produce  disease,  unless  it  is 
carried  to  excess.  The  practice  of  it  is  not  confined  to  man.  Monkeys 
are  often  masturbators,  bears  have  the  same  habit,  goats,  making  use 
of  the  mouth,  indulge  in  it,  turkeys  sometimes  practice  it  upon  a  round 
object,  like  a  smooth  stone.  In  the  human  being  it  is  practiced  by  both 
sexes  at  all  ages.  Females  are  much  less  given  to  it  than  males.  The 
majority  of  women  have  very  little  passion,  and  suffer  the  approaches 
of  a  lover  or  husband  largely  as  a  matter  of  complaisance.  There  are 
undoubtedly  numerous  exceptions  to  this  rule,  but  still  a  rule  it  is  that 
the  female,  naturally  modest,  retiring,  refined,  learns  what  passion  is 
only  as  the  result  of  education  after  marriage.  With  the  male  it  is 
different.  His  passion  is  natural.  He  often  has  erections  while  yet  a 
child,  and  sexual  yearnings  long  before  puberty.  Planque  *  mentions 
two  children  four  years  old  whose  sexual  organs  were  so  developed 
that  they  could  perform  sexual  intercourse.  Karely  does  a  boy  escape 
an  initiation  into  forbidden  pleasures  by  his  school-fellows  or  his  elders, 
and,  when  he  escapes  these,  he  is  still  very  apt,  when  handling  himself 
during  erection,  to  find  the  sensation  agreeable,  and  go  on,  really 
ignorant  of  what  he  is  doing,  until  he  becomes  a  confirmed  masturba- 
tor.  Male  babies  are  sometimes  handled  by  their  nurses  to  keep  them 
quiet,  a  practice  which  is  certain  to  beget  the  habit,  even  in  the  earliest 
years  of  life.  Stone  in  the  bladder,  irritation  of  the  prepuce  from 
retained  smegma,  traumatic  stricture  and  bladder-disease,  ascarides, 
etc.,  lead  a  child  to  handle  himself,  and  inevitably  end  in  masturba- 
tion, if  long  enough  continued ;  indeed,  there  are  so  many  causes, 
natural  and  unnatural,  why  a  boy  should  masturbate,  that  probably  few 
escape.  The  most  common  incentive,  however,  is  undoubtedly  instruc- 
tion, and  this  is  usually  received  by  children  from  other  boys  at  school. 

"  Op.  ciL,  art.  "  Accroisement." 


436  MALADIES  IXVOLVING   THE  GENITAL  FUNCTION. 

It  may  be  safely  assumed  that  a  large  proportion  of  mankind  have 
at  some  period  of  life  masturbated  more  or  less,  a^ul  it  is  equally  safe 
to  assert  that  at  least  ninety  per  cent  of  such  masturbators  are  not 
physictilly  injured  by  the  habit.  Sexual  indulgence  in  the  natural  way 
will  produce  evil  effects  if  carried  to  excess,  yet  it  is  probable  that  sex- 
ual intercourse  is  not  only  harmless,  but  even  bcncticial  in  moderation, 
when  carried  on  naturally — as  it  can  be  only  in  the  married  state.  It 
is  not  the  loss  of  seminal  fluid  which  is  of  the  first  importance  in  pro- 
ducing disease  from  sexual  excess,  but  the  nervous  shock  of  the  oft- 
repeated  orgasm.  Babies  and  young  children  lose  no  seminal  fluid, 
women  have  none  to  lose,  yet,  in  all  of  these,  evil  results  follow  excess, 
as  certainly  as  they  do  in  the  male  after  puberty.  It  is  probable  that 
any  succession  of  nervous  shocks  as  sharp  and  decisive  as  the  sexual 
orgasm,  even  although  they  were  purely  intellectual,  such  as  joy  or 
fear,  would  shatter  the  vitality  and  nervous  tone  of  an  individual,  per- 
haps as  much  as  masturbation.  Such  writers  as  Lallcmand,  Acton, 
Belliol,  certainly  make  too  much  of  the  solitary  vice,  wliile  quacks  find 
here  the  largest  and  most  lucrative  field  for  their  nostrums.  The  latter 
scatter  their  books  and  circulars  broadcast  over  the  land,  and  often, 
under  alluring  titles,  thrust  them  within  the  eager  grasp  of  the  young, 
the  inexperienced,  the  hypochondriacal,  of  the  nervous,  overworked,  un- 
married youth,  whose  sexual  needs,  stimulated  by  his  impure  thoughts, 
do  not  find  adequate  relief.  Here  their  tenets  find  ample  faith  and 
ready  acceptance,  and  errors  are  implanted  in  the  ingenuous  mind 
which  years  of  sober  after-thought  and  experience,  aided  by  the  sur- 
geon's careful  and  conscientious  advice,  are  scarcely  able  to  eradicate. 
Self-abuse  is  not  confined  to  youth ;  middle  and  old  age  are  not  free 
from  it.  The  numerous  foreign  bodies  found  in  the  urethra  and  blad- 
der attest  the  tendency  that  men  of  all  ages  have  to  meddle  with  their 
genitals.  Dr.  J.  E.  Wood,  of  K'ew  York,  had  a  long,  thick,  leather 
thong  which  he  was  called  upon  to  remove  from  a  patient,  who  had 
introduced  it  through  his  urethra  into  his  bladder,  and  amused  him- 
self by  Avorking  it  backward  and  forward  until  the  free  end  in  the 
bladder  became  knotted,  and  Dr.  Wood  was  called  upon  to  extract  it, 
finding  the  patient  with  several  inches  of  the  thong  projecting  from 
his  meatus. 

The  use  of  tobacco,  alcohol,  and,  it  might  be  added,  tea,  is  as  wide- 
spread as  is  the  habit  of  masturbation  ;  and  each  of  these  habits,  or 
certainly  the  first  two,  inflict  as  much  injury  upon  the  human  race  as, 
in  all  probability,  does  the  secret  vice  ;  yet  who  would  affirm  that 
every  man  who  smoked  would  have  headache,  dyspepsia,  heartburn, 
neuralgia,  intermission  of  the  heart-beat,  etc.  ;  would  become  thin, 
depressed,  nervous,  sleepless — effects  all  of  which  may  be  produced  by 
an  excess  of  tobacco  ;  or  that  another  who  drank  liquor  would  neces- 
sarily have  delirium  tremens,  cirrhosis  of  the  liver,  fatty  kidney,  and 


SELF-ABUSE.  407 

die  with  ascites  and  Bright's  disease  ?  As  it  is  with  whisky  and  to- 
bacco, so  it  is  with  masturbation  carried  to  excess.  It  is  capable  of 
producing,  it  must  be  recognized,  the  most  serious  results,  among 
which  idiocy,  insanity,  epilepsy,  dementia,  physical  prostration,  hypo- 
chondria, impotence,  and  sterility,  are  prominent,  but  these  are  prac- 
tically very  rare — so  rare,  indeed,  that  they  arc  encountered,  as  a  rule, 
only  by  the  specialist,  and  very  rarely  by  him  ;  and,  finally,  even  when 
these  serious  results  can  be  traced  to  masturbation  as  a  first  cause,  it 
will  often  be  found  that  some  other  cause  has  acted  in  conjunction 
with  the  masturbation,  such  as  a  blow  on  the  head,  hereditary  tend- 
ency to  the  disease  in  question,  natural  feebleness  of  nervous  tone,  ir- 
regular and  self-indulgent  habits,  abuse  of  stimulants,  syphilis.  Hence 
it  becomes  plain  that,  while  the  intelligent  physician  must  recognize 
the  possible  physical  evils  produced  by  masturbation,  he  should  oppose 
himself  boldly  to  tliat  sickly  sentimentality  which  shrouds  in  mystery 
one  of  the  failings  of  our  physical  nature,  because  it  involves  the  sexual 
function,  and  should  try  to  look  the  subject  honestly  in  the  face,  and 
handle  it  as  if  it  were  a  problem  in  mathematics. 

Looking  at  masturbation  in  this  way,  the  truth  is  that  the  majority 
of  mankind  who  indulge  in  it  do  so  just  before  and  after  puberty. 
Most  of  them  are  ignorant  at  first  that  they  are  harming  themselves, 
but  they  soon  find  it  out  by  one  means  or  another,  and  then  sooner  or 
later  give  it  up.  The  longer  and  the  more  frequently  they  yield  to 
the  vicious  habit  the  stronger  does  its  hold  become,  so  that  in  case 
they  escape  the  mental  and  physical  disorders  to  which  excessive  venery 
in  extreme  cases  may  give  rise,  still  they  may  jDay  the  penalty  of  excess 
by  some  diminution  of  vigor  in  after-life,  by  throwing  confusion  into 
their  sexual  hygiene,  and  establishing  sexual  necessities  which  they 
find  it  difficult  to  meet  suitably ;  and,  finally,  they  may  continue  on 
through  life  victims  to  a  perverted  sexual  sense,  shunning  women, 
from  whom  they  aver  that  they  derive  no  pleasure,  totally  wrecked  as 
to  their  morale,  often  hypochondriacs,  and  suffering  from  all  sorts  of 
functional  distress,  phj^sical  and  intellectual,  real  and  fancied. 

The  chief  reason  why  so  much  is  said  of  venereal  excess  by  mastur- 
bation, and  so  little  of  sexual  excess  in  the  natural  way,  is,  that  the 
former  is  so  much  more  common,  and  not  that  the  act  itself  is  johysic- 
ally  more  harmful.  The  solitary  vice,  as  it  is  aptly  styled,  may  be 
practiced  on  all  occasions,  even  in  company,  by  the  hand  in  the 
pocket,  or  by  friction  against  some  prominent  object.  In  schools,  not 
infrequently,  boys  practice  it  upon  each  other ;  but,  generally,  mas- 
turbation is  performed  in  bed,  and  in  solitary  places,  where  there  is 
no  possibility  of  disturbance.  Hence  the  frequency  of  its  perform- 
ance is,  in  some  cases,  very  great,  and  the  effects  of  often-repeated 
nervous  shock  more  pronounced.  Sexual  intercourse,  on  the  other 
hand,  requires  the  consent  of  two  individuals,  and  opportunities  which. 


43S  M.\XADIES  INYOLVIXG   THE   GENITAL  FUXCTION. 

relatively,  are  hard  to  find.  Moreover,  a  man's  moral  sense  will  often 
keep  him  from  committing  excess  with  a  woman,  wiien  nothing  will 
restrain  him  while  alone.  In  married  life,  excess  is  the  exception  ; 
sexnal  hygiene  is  more  apt  to  be  correct,  man  is  in  his  natnral  condi- 
tion, other  emotions  enter  largely  into  his  daily  life,  and  it  is  rare  that 
the  snrgeou  encounters  in  his  practice  a  man  happily  married  com- 
plaining of  any  disorder  of  the  genito-urinary  system,  except  those  of 
a  purely  jihysical  nature. 

Sy?npfonit<  of  Masturbation. — A  young  child  who  has  been  taught 
to  masturbate  will  be  seen  constantly  at  work  at  his  genitals,  and  ob- 
served to  have  erections  with  unnatural  frequency.  Ko  further  signs 
are  needed.  Such  children  become  fretful,  peevish,  thin,  nervous,  ex- 
citable. They  sleep  badly,  have  a  haggard  look,  seem  to  be  prone  to 
convulsions,  and,  it  is  said,  are  apt  to  have  epilepsy. 

Boys  who  masturbate  to  excess  usually  have  a  long  prepuce  (they 
may  have  none,  for  Jews  masturbate)  ;  they  get  a  sallow  look,  have  a 
sheepish,  hang-dog  expression  ;  their  eyes  are  deep-set,  they  incline  to 
melancholy  broodings,  to  sitting  by  themselves,  and  reading  over  a  fire 
rather  than  to  joining  their  companions  at  play.  They  become  absent- 
minded,  and  their  memory  seems  defective.  The  hand  is  apt  to  be  cold 
and  moist  in  the  palm.  The  skin  is  often  pallid  ;  the  innocent  frank- 
ness of  youth  is  absent. 

The  young  man  is  over-shj',  unambitious,  he  shrinks  from  a  steady 
gaze,  blushes  readil}^  and  seems  to  be  conscious  of  having  done  some- 
thing unmanly  and  little. 

Men  who  masturbate  often  show  no  sign  of  the  habit.  They  are 
apt  to  be  cowardly,  mean-spirited,  poor  specimens  of  humanity  ;  but  it 
is  rare  for  adults  to  practice  masturbation  to  great  excess,  and,  if  they 
suffer  from  any  of  the  supposed  evil  consequences  of  the  habit,  it  is 
either  on  account  of  excess  in  earlier  life,  on  account  of  imperfect 
sexual  hygiene,  or  irregularly  gratified  sexual  desire,  their  symptoms 
assuming  a  multiplicity  of  expression,  and  generally  being  such  as  are 
arranged  under  the  term  hypochondria,  and  manifestly  not  dependent 
entirely  upon  masturbation,  since  the  same  symptoms  are  very  com- 
mon in  patients  who  do  not  masturbate,  who,  indeed,  are  perfectly 
continent,  and  since  they  are  not  infrequently  relieved  by  marriage. 
As  to  atrophy  of  the  genitals,  varicocele,  chorea,  epilepsy,  idiocy,  in- 
sanity, it  is  quite  doubtful  if  these  are  often  due  to  masturbation  act- 
ing alone ;  and  although  this  vicious  habit  may  be  the  most  impor- 
tant cause  in  a  given  case,  and  should  always  be  sought  for,  and  if 
possible  corrected,  yet  undoubtedly  usually  some  other  obscure  cause 
of  disease  is  in  action,  and  is,  perhaps,  to  l)lame  for  the  masturbation 
as  well  as  the  idiocy  or  epilepsy.  Dr.  Van  Buren  cut  out  a  piece  of 
the  vas  deferens  on  each  side  in  one  case,  without  success  in  ward- 
ing off  impending  idiocy  in  connection  with  excessive  masturbation. 


SELF-ABUSE.  439 

W.  L.  FoLsom  *  is  the  authority  for  the  statement  that  Dr.  Josiah 
Crosby,  of  'Now  Hampshire,  In  1843,  castrated  a  young  man  for  ap- 
proaching dementia  due  to  masturbation,  and  completely  cured  the 
patient.  Sometimes,  after  a  severe  blow  on  the  head,  the  intellect 
fails,  epile2)sy  comes  on,  the  boy  approaches  nearer  to  the  brute  and  is 
found  to  masturbate  in  excess,  and  this  result  of  his  injury  frequently 
is  blamed  as  the  cause  of  all  his  troubles. 

The  foregoing  remarks  are  not  intended  to  palliate  in  the  least  de- 
gree the  baseness  of  the  practice  of  self-abuse,  or  to  deny  that  lack  of 
l^hysical  and  sexual  vigor,  spermatorrhcBa,  neuralgia  of  the  urethra, 
etc.,  may  be  frequently  caused  by  its  excessive  indulgence,  but  they 
are  intended  to  oppose  the  idea,  seemingly  so  prevalent,  that  very  few 
men  indulge  in  the  secret  vice,  and  that  all  who  do  so  S'uffer ;  and 
they  are  also  intended  to  advance  the  proposition  that  in  the  vast 
majority  of  instances  masturbation  does  little  harm  to  the  individual, 
except  in  regard  to  his  morale.  It  unmans  him,  makes  him  untrue 
to  himself,  and  cowardly  ;  and  most  sensible  boys  find  this  out  before 
a  great  while,  and  give  up  the  practice,  which  they  feel  to  be  sapping 
their  manhood  and  self-esteem. 

Treatment. — It  is  infinitely  better  that  a  boy  should  never  mastur- 
bate, if  he  can  be  saved  from  it.  Prophylactic  treatment  may  save 
him.  In  the  case  of  babies  who  do  not  do  well,  nurses  should  be 
watched,  and  discharged  as  soon  as  there  is  any  evidence  that  they 
are  handling  the  child.  If  the  infant  have  already  acquired  the  habit, 
his  hands  must  be  tied  when  he  sleeps,  and  at  all  other  times  he  must  be 
watched  until  he  grows  out  of  the  habit.  Boys  should  always  be 
made  to  sleep  alone,  never  allowed  to  consort  habitually  with  any 
other  boy,  especially  if  the  latter  be  the  older ;  all  close  intimacies 
between  boys  of  different  ages  should  be  broken  up,  and,  on  the  ap- 
pearance of  any  of  the  signs  of  masturbation,  a  close  watch  should  be 
kept  up. 

It  is  not  good  policy  in  most  cases  to  ask  a  boy  if  he  fingers  his 
privates.  He  will  be  pretty  sure  to  say  no,  and  then  to  tell  other  lies 
to  substantiate  the  first.  It  is  the  safest  course  to  assume  the  fact 
after  a  careful  study  of  the  case,  and  the  boy,  thrown  off  his  guard  by 
the  statement  that  he  does  masturbate,  will  rarely  deny  it,  or  will  do 
so  in  such  a  feeble  manner — occasionally  with  such  overpositiveness — 
that  he  will  convict  himself.  Finally,  when  the  patient  has  confessed 
his  folly,  it  is  not  wise,  in  most  cases,  to  try  to  terrify  him  out  of  his 
habit  by  brilliant  and  exaggerated  statements  of  the  possible  misery 
he  may  bring  upon  himself  if  he  does  not  stop.  This  is  appealing  to 
a  base  motive,  fear  of  an  indefinite  evil  in  the  future,  and,  although 
sometimes  successful,  it  is  often  inadequate  to  the  proposed  end,  for  a 
healthy  boy  can  not  realize  what  it  means  to  be  sick ;  he  can  not 

*  "New  York  Medical  Record,"  July  16,  ISSl,  p.  84. 


440  MALADIES  IXVOLVIXG   THE   GEXITAL  FUNCTION'. 

understand  it,  and  consequently  is  not  afraid  of  it.  Tlie  method  of 
treatment  which  is  most  etleetive,  but  at  the  same  time  the  one  which 
requires  the  most  force  to  carry  out,  is  to  elevate  the  boy  out  of  his 
bad  habit,  to  shame  him,  to  make  a  man  out  of  him,  to  reason  with 
him,  and  talk  to  him  honestly  and  openly,  without  reserve  or  mysti- 
cism ;  to  sympathize  with  him,  not  to  wound  him  ;  to  study  him  and 
treat  him  morally.  This  course  will  succeed  with  the  greatest  num- 
ber, provided  only  sufficient  time  and  attention  be  given  to  it. 

When  a  man  comes  complaining  of  the  results  of  masturbation,  an 
attentive  study  of  his  symptoms  will  not  infrequently  disclose  his  dis- 
ease to  be  hypochondria,  and  his  malady  ungratilled  sexual  desire, 
with  often  some  neuralgia  of  the  vesical  neck.  His  training  should 
consist  in  encouragement  and  continence,  with  absolute  purity  of 
thought,  and  subsequently  marriage,  to  regulate  his  sexual  hygiene. 
After  marriage  it  is  rare  to  hear  any  further  complaint  from  these  cases 
— always  provided  there  is  really  nothing  more  than  functional  derange- 
ment at  the  bottom  of  the  patient's  complaint,  as  is  the  case  in  the 
vast  majority  of  instances. 

As  for  medicines,  they  are  of  little  or  no  value  ;  camphor,  bromide 
of  potassium,  or  lupulin  might  be  given  as  placebos,  but  it  is  doubt- 
ful if  they  are  of  any  efficacy.  Cold  sponge-baths,  out-door  sports, 
physical  fatigue,  sleeping  in  a  cool  room  on  a  hard  bed,  with  a  light 
covering,  are  all  useful ;  eating  lightly  at  night,  not  retiring  until 
very  sleepy,  and  rising  immediately  on  waking  in  the  morning,  are 
powerful  assistants  in  breaking  up  the  habit,  but  all  will  be  of  no  avail 
unless  the  morale  of  the  patient  be  elevated,  unless  he  keep  his 
thoughts  pure,  and  desire,  for  the  manliness  of  it  alone,  to  bo  rid  of 
his  bad  habits. 

POLLUTION. 

Pollution  is  a  term  applied  to  involuntary  emissions  of  semen  in 
ejaculation,  attended  by  a  venereal  orgasm,  more  or  less  marked.  Pol- 
lutions are  nocturnal  or  diurnal. 

Nocturnal  pollutions  are  exceedingly  common.  They  usually  ac- 
company an  erotic  dream,  and  the  jDatient  wakes  just  as  the  ejaculation 
is  occurring.  Sometimes,  when  sleep  is  profound,  the  patient  does  not 
wake,  or,  if  he  does,  he  forgets  his  dream.  The  sensation  of  pleasure 
undoubtedly  accompanies  ejaculation  in  these  cases,  but  is  faint  and 
forgotten.  Nocturnal  emissions  in  moderation  are  entirely  natural, 
and  by  no  means  a  sign  of  disease.  Their  frequency  compatible  with 
health  varies  with  the  purity  of  mind  and  the  sexual  vigor  of  the 
patient.  A  man  who  is  happily  married  rarely  has  nocturnal  emissions 
while  living  with  his  wife,  but,  if  he  leaves  her  for  several  weeks,  it  is 
natural,  and  entirely  the  rule,  that  there  should  be  a  formation  and 
collection  of  semen  which,  distending  the  seminal  vesicles,  excites 


POLLUTION.  441 

erotic  fancies,  and,  in  the  relaxed  condition  between  sleeping  and 
waking,  escapes  at  the  conclusion  of  a  dream.  Any  man  suffering 
from  ungratificd  sexual  desire  is  normally  in  a  condition  demanding 
relief  for  his  overdistended  seminal  vesicles,  and,  if  that  relief  be  not 
aiforded  in  some  way  by  the  patient,  it  will  come  spasmodically  during 
sleep.  This  is  all  the  more  certain  to  be  the  case  if  the  patient  has 
established  a  habit  of  rapid  "formation  of  semen  by  frequent  calls  for  a 
supply  of  the  same  in  excessive  sexual  intercourse,  or  masturbation 
practiced  as  a  habit  for  a  considerable  length  of  time  :  and  especially 
if,  when  natural  or  unnatural  gratification  is  given  up,  lascivious 
thoughts  are  indulged  in,  and  impure  associations  continued.  Occa- 
sionally nocturnal  emissions  may  be  overfrequent,  and  indicate  a  con- 
dition of  irritation  in  the  deep  urethra — some  modification  of  neural- 
gia of  the  vesical  neck  which  requires  treatment. 

Treatment. — When  emissions  do  not  exceed  three  times  weekly  they 
should  be  disregarded,  and  attempts  made  only  to  purify  the  thoughts 
of  the  patient,  elevate  his  tone,  and  get  him,  if  possible,  happily  mar- 
ried. Where  they  become  very  frequent,  as  nightly  or  several  times  a 
night  for  a  considerable  time,  besides  the  employment  of  all  known 
tonic  and  hygienic  means  and  the  measures  detailed  above,  certain 
special  attempts  to  correct  the  habit  are  advisable.  The  patient  should 
exercise  and  develop  his  muscular  system.  He  should  endeavor  to 
sleep  soundly,  by  tiring  himself  out  through  the  day  by  physical  work. 
Dry  frictions,  cold  bath,  cold  douche,  locally,  are  useful.  He  should 
sleep  on  a  hard  bed,  lightly  covered.  The  stomach  should  not  be  full 
on  retiring.  Most  patients  have  involuntary  emissions  toward  morn- 
ing, and,  waking,  find  themselves  lying  on  their  back.  This  position, 
with  the  bladder  somewhat  distended,  tends  to  beget  erection,  and,  by 
avoiding  it,  pollution  may  be  escaped.  This  is  accomplished  by  causing 
the  patient  to  tie  a  towel  round  his  waist  on  retiring,  with  a  hard  knot 
in  the  back  over  the  spine.  When  he  lies  upon  this  knot  it  will  wake 
him.  Besides  these  means,  among  all  of  which  purity  of  thought 
comes  first,  bromide  of  potassium,  camphor,  and  luj)ulin  may  be 
given  internally,  with  strychnine  and  a  mineral  acid,  or  sucli  tonic  as 
the  physical  conditions  seem  to  call  for,  and  locally  decided  advantage 
may  be  derived  from  the  gentle  use  of  the  steel  sound,  as  in  neuralgia 
of  the  vesical  neck,  and  finally  the  cujDped  sound  with  tannin,  as  in 
spermatorrhoea,  or  prostatic  injection  with  nitrate  of  silver,  which  I 
have  found  of  great  value  in  some  cases.  Different  mechanical  devices 
appear  from  time  to  time  for  treating  pollution,  their  object  being 
either  to  prevent  the  patient  from  handling  himself  during  sleep  or 
to  awaken  him  before  emission  when  he  gets  an  erection.  I  believe 
them  usually  to  be  without  value,  and  as  liable  to  do  harm  as  good 
by  keeping  the  patient's  mind  concentrated  upon  his  malady,  and  lead- 
ing him  to  attach  too  much  importance  to  the  physical  act  of  emis- 


442  MALADIES   INVOLVING   THE   GENITAL   FUNCTION. 

sioii.  I  liavo  used  one  upon  a  patient  wliich  started  a  battery  and  gave 
an  electric  shock  in  the  back  wlien  erection  came  on.  Verneuil  used 
a  similar  instrument,  which  caused  a  bell  to  ring  when  erection  came 
on,  and  he  reports  a  successful  case,*  as  does  also  Tillaux.f  There 
is  another  machine,  a  ring,  which  lightly  encircles  the  penis,  but  when 
distended  by  erection  causes  pain  and  awakens  the  sleeper.  I  think 
these  mechanical  means  bad,  and  unsatisfactory  in  their  result.  It  is 
attacking  only  one  symptom  and  letting  tlie  real  malady  go. 

Diin'fial poUiifioH  is  rare.  In  some  impressionable  patients,  espe- 
cially if  suffering  from  prostatic  irritability  due  to  venereal  excess,  the 
sight  or  thought  of  certain  women  will  produce  ejaculation,  as  may  a 
touch  upon  the  glans  penis.  Ejaculation  of  semen  may  be  produced  by 
a  variety  of  causes.  Lallemaud  speaks  of  a  man  who  could  produce 
it  by  striking  his  head  with  his  knuckles.  Sudden  injuries  to  the  spine 
sometimes  produce  the  same  effect.  Lallemand  quotes  from  Hedel- 
hofer  that  a  man  fell  upon  the  sacrum,  and  immediately  had  an  ejacu- 
lation. In  decapitation  by  the  guillotine,  unless  the  neck  is  severed 
too  low,  ejaculation  is  quite  common. 

The  treatment  of  diurnal  pollution  is  by  steel  sounds  and  local 
astringents  to  the  prostate,  together  with  most  of  the  means  detailed 
for  nocturnal  emissions.  Circumcision  should  be  performed  if  the 
glans  penis  is  sensitive. 

SPERMATOIlB,H(EA. 

Few  terms  are  more  abused  and  distorted  in  their  significance  than 
spermatorrhoea.  The  young  man  into  whose  hands  some  pamphlet  on 
"Manhood  Restored"  has  fallen,  imagines  himself  hopelessly  doomed 
to  impotence,  paralysis,  and  idiocy,  because  he  has  spermatorrhoea, 
which  spermatorrhoea  consists  in  nocturnal  pollution,  escape  of  mucus 
during  prolonged  erection,  appearance  of  amorphous  phosphates  in  his 
urine — often  in  a  gleety  discharge,  due  to  stricture  or  a  damaged 
patch  of  mucous  membrane  in  the  urethra,  and  sometimes,  where  the 
diseased  mind  of  a  youth  suffering  from  ungratified  sexual  desire  can 
find  nothing  else  to  confirm  its  suspicions,  the  natural,  healthy,  floc- 
culent  cloud  of  mucus  collecting  normally  in  all  urine,  after  it  has 
stood  a  while,  is  pointed  to,  in  dejected  triumph,  as  a  demonstration 
of  the  never-ending  loss  of  seminal  fluid.  Occasionally  a  patient  will 
even  bottle  his  urine  and  keep  it  a  week,  until  it  has  decomposed, 
and  then  bring  it  to  the  surgeon  in  its  murky  condition  to  prove  that 
he  has  "spermatorrhoea." 

Most  of  the  symptoms  whicli  a  patient  usually  mistakes  for  sperma- 
torrhoea have  been  already  disposed  of  in  other  portions  of  this  work, 

*  "  Bull,  dc  la  Soc.  de  Chir.,"  May  5,  1877,  p.  298. 
t  Ibid.,  Nov.  7,  1877,  p.  535. 


SPERMATORRHCEA.  44.3 

and  need  not  be  again  alluded  to  (gleet,  phosphatic  urine,  vesical  mu- 
cus, decomposing  urine,  etc.).  It  falls  to  the  lot  even  of  the  special- 
ist to  see  but  very  few  cases  of  true  spermatorrhcea. 

Spermatorrhoea  is  an  escape  of  seminal  fluid  containing  sperma- 
tozoa, without  ejaculation  and  without  pleasurable  orgasm — usually 
at  stool,  with  the  urine,  or,  to  a  slight  extent,  at  all  times.  During 
prolonged  erection  under  intense  sexual  excitement,  a  small  amount 
of  true  seminal  fluid  is  apt  to  escape  into  the  prostatic  sinus,  and  to 
be  passed  at  the  next  urination.  This  may  happen  to  any  one  occa- 
sionally, and  does  not  amount  to  disease. 

Causes.  — Spermatorrhcea  sometimes  follows  excessive  masturbation ; 
occasionally  it  appears  as  a  sequence  of  acute  general  prostration — as 
after  typhoid  fever ;  it  may  come  on  in  connection  with  imperfect 
digestion  and  general  nervous  distress  from  overwork  or  other  cause, 
or  follow  chronic  disease,  of  the  inflammatory  type,  of  the  floor  of  the 
prostatic  sinus  and  seminal  vesicles. 

Symptoms. — In  true  spermatorrhoea  it  is  usual  for  spermatic  fluid 
in  small  quantity  to  pass  from  the  meatus  during  defecation,  esjiecially 
if  the  patient  is  constipated,  and  for  a  certain  amount  of  the  same 
fluid  to  be  voided  during  urination,  particularly  in  the  morning ; 
while,  occasionally,  jolting,  riding,  etc.,  cause  a  little  oozing  of  a  blu- 
ish fluid  from  the  meatus,  which,  on  examination,  is  found  to  contain 
spermatozoa.  These  symptoms  alone  constitute  spermatorrhoea,  or 
indeed. the  disease  may  be  said  to  exist  where  the  urine  habitually  con- 
tains spermatozoa,  although  no  semen,  as  such,  is  involuntarily  passed 
through  the  urethra.  The  subjective  symptoms  of  spermatorrhoea  are 
most  varied — very  often  the  patient  does  not  know  lie  has  the  disease. 
He  complains  of  some  feeling  of  weight  in  the  prostatic  region,  of  dys- 
pepsia or  some  nervous  derangement,  has  little  care  for  his  sexual 
functions,  and  is  not  disturbed  on  the  subject  of  impotence  ;  presents, 
indeed,  a  most  strongly  marked  contrast,  as  far  as  expressions  of  dis- 
tress go,  with  the  hypochondriacal  patient  imagining  himself  impotent 
from  spermatorrhcea,  and  taxing  the  capacity  of  his  language  to  ex- 
press his  woe.  Patients  with  true  sj)ermatorrhoea  are  not  by  any 
means  necessarily  impotent,  but  their  sexual  appetite  is  usually  mor- 
bid, excessive,  or  feeble,  perhaps  unnatural  and  perverted,  while  sexual 
power  is  generally  diminished.  In  many  cases  the  general  symptoms 
are  those  of  great  lack  of  nervous  tone,  dyspepsia,  headache,  melan- 
choly, neuralgia,  loss  of  spirits,  pains  in  the  back,  groins,  testicles, 
vesical  irritability.  Such  patients  tend  to  grow  thin,  to  lose  their 
ambition  and  their  zest  for  all  ordinary  pursuits,  to  run  down,  be- 
come fanciful,  indeed  hypochondriacal,  and  often  to  fret  seriously  and 
unceasingly  about  their  malady,  of  which  they  entertain  only  faint 
hopes  of  a  cure,  which  they  urgently  demand.  Finally,  in  the  most 
severe  cases,  all  the  above  symptoms  are  aggravated  ;  the  penis  shrivels. 


444  M.VLADIES   INVOLVING   THE   GENITAL  FUNCTION. 

the  testicles  become  small,  flabb)%  very  sensitive,  not  infrequently  nen- 
raJgic,  the  veins  of  the  cord  largo  and  full ;  the  loss  of  somen  contin- 
ues for  a  long  time,  finally  becomes  thinner,  more  like  simple  mucus, 
and  at  last  ceases  to  contain  spermatozoa,  being  made  up  of  the  fluids 
of  the  seminal  vesicles,  the  prostate,  and  Cowper's  glands.  At  last  the 
patient  becomes  truly  impotent,  incapable  of  erection.  This  malady 
does  not  kill.  I  know  several  patients  who  have  had  it  during  most  of 
my  professional  life-time — and  one  old  gentleman  who  was  on  Dr.  Van 
Buren's  books  long  before  my  day,  who  enjo3's  excellent  health  and 
has  nevertheless  true  spermatorrluea,  and  has  had  it  more  than  fifty 
years.  Many  cases  are  positively  incurable,  some  get  well — medicine 
is  of  little  or  no  value.  Precisely  the  same  symptoms  as  those  found 
in  spermatorrhopa  may  exist  in  connection  with  oxaluria,  azoturia, 
lithiasis,  and  be  found  with  various  jn-ostatic  and  deep  urethral  neu- 
roses when  there  is  absolutely  no  seminal  loss  whatever,  and  on  the 
other  hand  I  have  several  times  found  true  spermatorrhoea  when  not 
one  of  the  usual  symptoms  of  the  malady  was  present  except  the 
habitual  loss  of  seminal  fluid  in  the  urine.  The  absolute  lack  of  symp- 
toms in  true  spermatorrhoea,  however,  is  very  rare.  It  is  unfortunate 
that  so  many  text-books  ascribe  value  to  the  use  of  drugs  in  this  mal- 
ady. It  leads  to  despondency  on  the  part  of  the  jiatient,  and  places 
his  physician  in  a  false  light  before  his  eyes.  A  few  cases  can  be 
cured,  and  something  can  be  done  for  others,  but  some  cases  remain 
uncured,  and  the  less  they  potter  with  themselves  the  better.  If  a 
positive  local  treatment,  with  perhaps  some  tonics  when  required,  fails 
to  cure,  the  patient  will  be  wise  to  accept  his  malady  as  he  would  some 
deformity  which  others  can  not  see,  and  think  as  little  of  it  as  possi- 
ble, keeping  his  mind  pure,  and  his  thoughts  away  from  the  subject. 

Treatment. — All  the  hygienic,  general,  and  local  measures  advised 
for  cases  of  pollution  and  sexual  weakness,  already  given,  become  im- 
peratively necessary  in  treating  true  spermatorrhoea,  with  the  hope  of 
success  in  mild  cases,  and  without  entire  despair  in  severe  ones.  The 
use  of  the  steel  sound  helps  to  give  tone  to  the  parts.  Eoubaud  thinks 
well  of  ergot — two  to  eight  grains  daily — in  atonic  cases.  The  use  of 
a  local  astringent  to  the  prostatic  sinus  is  often  of  marked  ad- 
vantage. The  best  agent  for  effecting  this  is  nitrate  of  silver 
in  solution,  used  as  a  deep  urethral  instillation  in  the  manner 
detailed  when  describing  my  deep  urethral  syringe.     Formerly 


Pig.  110. 

I  employed  tannin  with  the  cupped  sound  (Fig.  110),  filling  in  the 
cups  with  a  paste  of  glycerin  and  tannin,  but  of  late  3'ears  I  seldom 


EROTOMANIA— BLUE  SPERM.  445 

use  it.  The  nitrate  of  silver  gives  far  better  results.  I  never  use  a 
solution  stronger  than  sixty  grains  to  the  ounce,  and  place  only  three 
to  five  drops  of  this  in  the  deep  urethra.  Often  as  much  good  can  be 
effected  with  a  solution  of  ten  grains  to  the  ounce.  Lallemand's  in- 
strument for  actual  cauterization  with  solid  nitrate  of  silver  should 
never  bo  used.  It  destroys  tissue,  and  may  substitute  a  worse  disease 
(sterility)  for  the  comparatively  trivial  one  of  spermatorrhoea,  by  ob- 
literating in  the  cicatrix  the  orifices  of  the  ejaculatory  ducts. 

EROTOMANIA. 

Erotomania  is  a  species  of  insanity.  It  is  a  disease  of  the  central 
nervous  system,  characterized  by  the  existence  of  erotic  desires  with- 
out the  power  of  accomplishing  them,  sometimes  apparently  without 
the  wish  to  do  so,  as  in  a  case,  which  is  on  record,  of  a  patient  so 
affected,  who,  when  asked  what  he  would  do  if  put  to  bed  with  a 
woman,  remarked  that  he  "  would  go  to  sleep.'*  The  malady  is  not  a 
disease  of  the  genitals,  and  does  not  call  for  any  more  lengthy  descrip- 
tion here. 

SEXUAL    PEHVERSION. 

This  is  a  disease  of  the  mind  rather  than  the  body,  and  no  lengthy 
description  here  is  proper.  Westphal  *  and  Kraf t-Ebing  f  have  writ- 
ten learnedly  about  the  matter.  Casper  gave  the  name  "Lesbian 
love"  to  that  perverted  instinct  which  inclines  a  woman  sexually 
toward  another  woman  rather  than  toward  a  man.  Sometimes  the  dis- 
ease takes  the  form  of  sexual  excitement  being  produced  in  a  man  by 
wearing  articles  of  female  attire.  This  has  been  called  " gynomania."  X 
Intercourse  between  women  is  also  called  tribadism.  Between  man 
and  man,  or  unnatural  intercourse  between  man  and  woman,  is  called 
sodomy.  If  the  victim  is  a  boy  it  is  called  paederasty.  Ulrichs  has 
given  the  name  "  Timings  "  to  those  whose  sexual  sense  is  only  stimu- 
lated by  consorting  with  one  of  their  own  sex.  Such  individuals  in 
their  dress,  acts,  habits,  walk,  etc.,  desire  to  act  the  part  of  one  of  the 
opposite  sex.  They  abhor  natural  sexual  intercourse.  The  subject  is 
a  disgusting  one,  and  the  very  contemplation  of  it  is  degrading. 

BLTJE    SPERM. 

Guelliot  *  reports  a  case  of  '^  spermatorrhee  et  cyauospermie." 
Ultzmann  has  called  attention  to  the  same  phenomenon,  which  he 
ascribes  to  the  presence  of  indigo, 

*  "Archiv  f.  Psychiatric  und  NerYcnkrankheiten,"  vol.  vi,  p.  620. 
f  Ibid.,  vol.  vii,  p.  305,  and  "  Irrenfreund,"  vol.  xxiv,  No.  1,  1884. 
X  "New  York  Medical  Eecord,"  March  19,  1881,  p.  336. 

*  "Ann.  des  Mai.  des  Org.  Genito-Urinaires,"  May,  1886,  p.  294. 


446  MALADIES  INVOLVIXC   THE  GENITAL  FUNCTION. 


SATYRIASIS. 


Satyriasis  is  constant  desire  with  erection  ;  erotic  delirium.  It  is 
also  a  brain-disease.  An  illustrative  case  is  quoted  by  Acton  *  of  an 
old  man  who  was  eminently  satyriasic,  so  much  so  that  he  would 
masturbate  in  the  presence  of  ladies.  Dying,  a  tumor  of  the  size  of  a 
split  pea  was  found  in  the  pons  Varolii. 


PRIAPISM. 

Priapism  is  more  or  less  continuous  erection  without  desire.  With 
some  forms  of  priapism  intercourse  with  ejaculation  may  take  place. 
The  connection  between  injuries  of  the  cerebellum  and  spinal  cord  and 
erection  has  long  been  observed.  Koubaud  f  quotes  Serres  in  stating 
that  out  of  eleven  cases  of  cerebellar  hasmorrhage  erection  of  the  penis 
was  noted  six  times.  Death  by  hanging  is  often  accompanied  by  par- 
tial erection.  After  injuries  to  the  spine,  and  in  some  diseases  of  the 
cord,  producing  paraplegia,  erections  are  often  absent,  returning  as  the 
paralysis  improves.  On  the  other  hand,  certain  diseases  and  injuries 
of  the  cord  are  notably  attended  by  priajjism,  disappearing  as  the  para- 
plegia gets  well.  Lallemand  J  quotes  a  case  from  Fages  of  an  officer 
who  was  thrown  from  his  horse,  and  became  at  once  paraplegic,  and 
simultaneously  had  priapism.  The  latter  annoyed  him  excessively,  as 
it  produced  retention,  relievable  only  by  local  and  general  refriger- 
ants, which  reduced  the  erection.  As  his  paraplegia  gradually  got 
well  his  priapism  ceased. 

Lallemand  gives  another  very  interesting  case  *  of  a  soldier,  who, 
climbing  out  of  garrison  to  see  his  mistress,  fell  upon  his  sacrum  and 
became  partially  paraplegic  with  priapism.  He  had  no  venereal  desire, 
yet,  because  the  priapism  interfered  with  his  making  water,  he  at- 
tempted frequently  to  free  himself  of  it  by  masturbation,  but  without 
success — there  was  no  ejaculation.  On  one  occasion,  with  the  mistress, 
on  attempting  to  see  whom  he  had  acquired  his  malady,  he  indulged 
in  copulation  almost  continuously  for  several  hours,  until  he  had  ex- 
hausted his  partner— but  all  to  no  effect.  He  had  no  pleasure  or 
ejaculation,  yet  when  asleep  he  had  lascivious  dreams,  with  ejaculation 
and  slight  sensation.  This  was  a  mixed  case,  since  some  of  its  charac- 
teristics are  those  of  aspermatism. 

The  effect  of  large  doses  of  cantharides  in  producing  erection  with- 
out desire  is  well  known. 

Prolonged  mental  exertion,  overanxiety,  and  other  causes  capable 
of  reducing  the  tone  of  the  nervous  system  are  sometimes  attended 
by  priapism,  due  perhaps  (immediately)  to  some  local  injury  such  as 

*  "  On  the  Reproductive  Organs,"  fifth  edition.  t  Op.  cit.,  vol.  ii,  p.  62. 

+  Op.  cit.,  p.  280.  *  Op.  ciL,  vol.  ii,  p.  64. 


ASPERMATISM.  447 

gonorrhoea,  the  j)assagc  of  a  stone,  the  introduction  of  a  sound.  Pria- 
pism not  very  infrequently  attends  some  of  the  neurotic  prostatic 
affections,  especially  in  patients  whose  nerve-force  is  defective.  Leu- 
cocythasmia  as  a  cause  of  persistent  priapism  has  heen  noted  by  many 
writers.  Peabody  *  in  two  papers  summarized  our  knowledge  on  the 
subject  and  gave  some  cases  of  his  own.  Salzer  f  discusses  the  various 
theories  of  immediate  cause — extravasation  of  blood  in  the  corpora 
cavernosa,  impeded  circulation  in  the  smaller  vessels,  formation  of 
thrombi  due  to  the  altered  condition  of  the  blood,  and  irritation  of 
the  nervi  corigentes — and  decides  in  favor  of  the  last,  in  some  cases 
at  least.  Wetherell,  J  Ketli,  Longuet,  and  other  names  are  known  in 
connection  with  this  subject.  Mackie  *  notes  a  case  of  persistent  pria- 
pism lasting  twenty-one  days  in  an  old  man  of  seventy.  After  nine- 
teen days  the  right  corpus  cavernosum  swelled,  incontinence  came 
on  with  paraphimosis,  all  relieved  by  incising  the  swelling,  which  dis- 
charged much  black,  half-decomposed  blood.  A  chill  preceded  all 
these  phenomena.  Mackie  thinks  a  small  extravasation  in  the  corpus 
cavernosum  was  the  immediate  cause  of  the  priapism. 

Schwerin  |  has  a  case  of  cantharidal  strangury  without  erotic 
symptoms.  He  agrees  with  Palle  in  dropping  cantharides  from  the  list 
of  aphrodisiacs,  but  the  cases  of  A.  Pare,  Chauvel,  and  others  quoted 
by  Sonnenschein,^  go  to  show  that  the  erotic  may  be  roused  to  the 
fullest  extent  by  poisonous  doses  of  cantharides. 

Priapism  in  children  is  often  due  to  stone  in  the  bladder,  tight  pre- 
puce, worms  in  the  rectum,  etc.  Extreme  cases  are  on  record  where 
priapism  has  terminated  in  gangrene  of  the  penis. 

Treatment. — Priapism  usually  gets  well  under  hygienic  and  symp- 
tomatic treatment,  beyond  which  no  special  measures  can  be  suggested, 
except  irritating  the  lower  part  of  the  spine,  blistering  the  peringeum, 
an  India-rubber  seton  at  the  nucha,  possibly  the  use  of  electricity,  and 
strychnine,  ergot,  bromide  of  potassium  tentatively,  notably  in  can- 
tharidal priapism.     Iodide  of  potassium  has  been  successfully  used.  J 

ASPERMATISM. 

Aspermatism  is  a  peculiar  condition  of  very  rare  occurrence,  in 
which  there  is  competent  erection,  sometimes  moderate  sexual  desire, 
sometimes  none  at  all,  no  ejaculation  of  semen  possible  during  sexual 

*  "New  York  Medical  Journal,"  May,  1880,  p.  463,  and  September,  1880,  p.  272. 
f  "Med.-chir.  Rundschau,"  June,   1879,  and  "Bcrl.  klin.  Wochensclirift,"  1879,  Na 


46. 


X  "  New  York  Medical  Record,"  August  14,  1880,  p.  192. 

*  "Edinburgh  Medical  Journal,"  November,  1872. 

II  "Berl.  klin.  Wochenschrift,"  November,  1873. 

^  "  Handbuch  der  gerichtlichcr  Chemie,"  p.  266  et  seq. 

I  "  Lancet,"  May  14,  1887. 


448  -MALADIES   IXVOLVIXG   THE   GEXITAL   FrXCTIOX. 

intercourse.  A  uumber  of  observers  have  noted  this  i)ecnliar  condi- 
tion. Ult/mann  *  lias  a  typical  case.  In  the  cases  observed  by  the 
authors  the  i)atients  have  been  physically  vigorous,  capable  of  pro- 
longed sexual  exercise,  but  utterly  unable  in  any  voluntary  way,  in 
sexual  intercourse  or  otherwise,  to  excite  an  orgasm  or  have  a  seminal 
emission.  Every  case  has  confessed  to  having  lascivious  dreams,  and 
to  have  aAvakened  with  a  pleasurable  sensation  and  found  seminal  lluid 
upon  the  night-di'css. 

A  full-sized  sound  passed  into  the  urethra  produces  the  ordinary 
sensations  in  the  fore  part  of  the  canal,  but  the  prostatic  urethra  is 
absolutely  insensitive. 

The  theory  advanced  to  account  for  this  strange  malady  is  that,  by 
reason  of  spasm  about  the  ejaculatory  ducts,  the  semen  is  prevented 
from  getting  into  the  prostatic  sinus.  This,  however,  is  untenable ; 
for,  were  there  desire  and  pleasure,  prostatic  mucus  would  be  secreted 
in  excess,  and  would  be  thrown  out  by  ejaculation,  while  the  semen 
proper  would  collect  and  distend  the  seminal  vesicles  and  ducts  below 
the  ejaculatory  orifices,  and  would  escape  and  flow  away  from  the 
meatus,  after  the  relaxation  of  spasm,  brought  about  by  the  fatigue 
following  prolonged  sexual  intercourse.  But  this  is  not  the  case.  The 
fault  is  evidently  in  the  nerves.  There  is  no  pleasurable  sensation,  no 
call  for  secretion  of  prostatic  mucus,  or  for  a  supjily  of  spermatic  fluid. 
There  is  anaesthesia  of  the  prostatic  sinus,  and,  although  the  power  of 
having  an  orgasm  and  an  ejaculation  remains,  as  proved  by  dreams,  yet 
there  is  some  connecting  link  missing  in  the  chain  which  transforms 
friction  of  the  glans  into  pleasure  at  the  prostate,  and  finally  into 
secretion  in  the  testicle. 

Treatment. — Eoubaud  advises  antispasmodics,  on  the  theory  that 
muscular  contraction  is  the  essence  of  the  disease.  He  speaks  of  suc- 
cess in  one  case  by  blistering  the  perineum  and  powdering  for  several 
days  with  morphine.  No  rational  or  effective  treatment  has  yet  been 
devised. 

AZOOSPERMATISM. 

This  is  a  condition  in  which  there  is  spermatic  fluid,  but  no  sper- 
matic elements.  It  exists  in  many  cases  after  double  gonorrhoeal 
epididymitis,  in  atrophy  of  the  testicle  when  the  fluid  is  watery  and 
may  contain  Boettscher's  crystals,  and  in  suppuration  of  both  seminal 
vesicles. 

*  "Ueber  maunliche  Sterilitat,"  "  Wicn.  med.  Prcssc,"  Nos.  1-3,  187S. 


SPASM   OF   THE   CllEMASTER.  449 


CHAPTEE  XXYII. 

DISFASES   OF  TUB  CORD. 

Anatomy.— Spasm  of  Crcmastcr.— Varicocele,  mild,  severe. 

The  cord  is  made  up  of  the  vas  deferens,  the  habenula  or  remains 
of  the  peritoneal  process  going  from  the  tunica  vaginalis  to  the  abdo- 
men, vessels  and  nerves,  all  held  together  by  meshes  of  connective  tis- 
sue containing  unstriped  muscular  fiber  (internal  cremaster  of  Henle). 
Outside  of  these  there  is  a  continuous  layer  of  connective  tissue,  ad- 
herent to  the  tunica  vaginalis  below,  and  continuous  with  the  fascia 
transversalis  above,  called  tunica  vaginalis  communis.  Outside  of  this 
the  cremaster  muscle  lies  in  loops,  some  embracing  the  testicle  in  a  fan 
shape,  others  extending  only  a  short  distance  down  the  cord. 

The  arteries  are  the  sjDermatic  from  the  aorta,  the  deferential  from 
the  superior  vesical,  the  cremasteric  from  the  epigastric.  The  veins 
from  the  testicle  and  epididymis  unite  in  the  pampiniform  plexus,  and. 
constitute  the  bulk  of  the  cord.  The  larger  veins  have  valves  ;  they 
unite  usually  to  form  one  large  trunk,  which  empties,  on  the  left  side, 
into  the  renal  vein,  on  the  right  side  into  the  ascending  cava.  The 
spermatic  plexus  of  nerves  is  derived  from  the  renal,  aortic,  superior 
mesenteric,  hypogastric,  and  lumbar  (genital  branch  of  gen i to-crural 
nerve  supplying  the  cremaster). 

The  cremaster  muscle  varies  in  size  and  power  in  different  sub- 
jects ;  it  is  a  voluntary  muscle ;  most  persons  can  exercise  it  simul- 
taneously on  both  sides,  drawing  up  and  holding  the  testicles  against 
the  abdomen ;  occasionally  the  muscles  can  be  exercised  separately, 
one  testicle  being  elevated  while  the  other  is  lowered.  The  function 
of  the  muscle  is  to  assist  in  sustaining  the  testicle  by  its  tonic  contrac- 
tion, and  to  compress  the  organ  during  the  sexual  orgasm.  The  mus- 
cle is  subject  to  painful  spasmodic  contraction  in  kidney-colic,  in  neu- 
ralgia of  the  testicle,  and  sometimes  in  connection  with  prostatic  or 
urethral  irritation.  A  large  portion  of  the  cremaster  muscle  was  ex- 
cised by  the  late  Valentine  Mott  for  obstinate  spasm.  Cure  of  the 
prostatic  irritation  causing  it  relieves  the  spasm. 

The  spermatic  cord  is  rarely  diseased.  There  is  more  or  less  tur- 
gescence  of  the  veins,  with  sensibility  to  pressure,  in  the  different  in- 
flammatory conditions  of  the  testicle  and  vas  deferens,  and  injury  may 
lead  to  local  inflammation,  to  be  assuaged  by  rest,  hot  fomentations, 
etc.  Diffuse  and  encysted  hydrocele  and  h£ematocele  of  the  cord  have 
been  considered  in  connection  with  similar  conditions  of  the  testicle. 

29 


450  DISEASES  OF  THE  CORD. 

Fatty  tumors  are  occasionally  found.  They  can  not  bo  diagnosed 
from  encysted  hydrocele  without  an  exploratory  tapping,  and  are 
liable  to  be  mistaken  for  hernia  when  located  within  the  inguinal 
canal.  They  generally  occur  later  in  life  ;  if  large,  they  have  a  dougliy 
feel,  and  tiro  lobular  in  character ;  treatment  is  rarely  required.  In 
cases  of  doubt,  when  the  tumor  might  be  an  omental  hernia,  the 
utmost  care  is  necessary  in  operating  for  removal.  Calcareous  de- 
posits have  been  encountered  in  the  cord.  Vernouil  found  a  large, 
gummy  (syphilitic)  tumor  in  the  cord  ;  Lancereaux  and  Fournier  have 
recorded  cases. 

VARICOCELE. 

Varicocele  is  constituted  by  a  varicose  enlargement  of  the  pampini- 
form plexus  and  veins  of  the  cord.  In  a  mild  form,  it  is  perhaps  the 
commonest  affection  of  the  genital  organs.  It  has  been  estimated  that 
about  ten  per  cent  of  males  have  slight  varicocele.  It  occurs  almost 
invariably  on  the  left  side  ;  when  very  marked  on  this  side,  it  may  exist 
slightly  on  the  right,  but  varicocele  of  the  right  side  alone  is  almost 
unknown.  Pott  met  with  it  on  both  sides  only  once.  Breschet,  in 
one  hundred  and  twenty  operations,  operated  only  once  on  the  right 
side. 

Slight  turgescence  of  the  veins  of  the  cord  does  not  deserve  to  be 
called  a  disease.  The  chief  factor  in  its  production  is  ungratitied 
sexual  desire,  frequent  erotic  fancies  not  finding  relief,  or,  less  often, 
the  oj^posite  condition,  abuse  of  the  sexual  powers,  by  which  the  veins 
are  kept  constantly  engorged.  The  largest  proportion  of  slight  vari- 
coceles which  are  encountered  are  found  in  young  unmarried  men  or 
old  bachelors  ;  the  affection  rarely  commences  after  twenty-five  ;  it  is 
unusual  to  find  it  in'  a  married  man  whose  sexual  relations  are  satis- 
factory. The  slight  turgescence  of  the  veins  constituting  the  varico- 
cele of  the  young  bachelor,  and  often  causing  him  incessant  and  need- 
less alarm,  usually  disappears  after  marriage,  together  with  the  uneasy 
sensations  which  accompanied  it. 

Old  men  whose  testicles  are  inactive  rarely  have  varicocele,  though 
their  legs  show  many  tortuous  veins,  and  their  tissues  be  degenerating. 
This  fact  is  of  the  utmost  importance,  and  is  dwelt  upon  thus  early  in 
the  consideration  of  the  disease,  in  order  that  attention  may  be  spe- 
cially directed  to  it.  The  idea  that  slight  varicocele  is  often  a  sexual 
derangement,  a  functional  disorder  depending  upon  bad  sexual  hy- 
giene, is  not  brought  out  by  text-books,  and  is  rarely  appreciated  by 
practitioners.  Young  men  in  many  cases  distress  themselves  unceas- 
ingly, and  importune  their  surgeon  for  an  operation  to  cure  a  disorder 
which  would  be  more  speedily  and  effectually  removed  by  marriage. 

The  degree  of  varicocele  alluded  to  above  may  be  dismissed  briefly. 
It  is  found  upon  the  left  side ;  the  vessels  are  a  little  full,  the  cord 


VARICOCELE.  45 1 

loose,  feeling  like  a  small  bundle  of  earth-worms,  no  one  vessel  being 
exceptionally  large,  the  testicle  is  perhaps  oversensitive  (irritable), 
and-  there  is  usually  a  slight  dragging  sensation  in  the  groin,  but  be- 
yond this  nothing  except  the  fancied  ills  and  the  hypochondriacal 
complainings  of  the  young  man  who  is  cheating  Nature  or  abusing  her 
gifts.  The  proper  treatment  of  such  cases  is  found  in  the  employ- 
ment of  all  hygienic  and  tonic  measures.  The  patient's  mind  must 
be  diverted,  he  must  be  dissuaded  from  an  operation,  told  to  wear  a 
snugly-fitting  suspensory  bandage,  and  if  possible  to  forget  his  sex 
until  an  opportunity  of  marriage  affords  him  a  chance  to  get  well. 
As  a  local  measure,  the  free  application  of  cold  water  to  the  parts 
daily  is  a  very  useful  adjuvant. 

Varicocele  serious  enough  to  constitute  a  disease  and  demand  act- 
ive surgical  measures  for  its  relief  does,  however,  occur.  It  is  an  ex- 
aggeration of  the  milder  form ;  it  comes  on  in  early  manhood,  and 
has  no  connection  with  varices  of  the  legs  or  anus  (haemorrhoids).  It 
is  found  on  the  left  side,  rarely  on  the  right.  The  cause  of  this  is 
believed  to  lie  in  the  following  facts  :  The  left  testis  hangs  habitually 
lower  than  the  right ;  only  the  larger  veins  of  the  cord  have  valves  ;  the 
left  vein  empties  at  a  right  angle  into  the  left  renal  vein,  the  right  at 
an  acute  angle  into  the  ascending  cava ;  the  position  habitually  as- 
sumed by  men,  of  standing  on  the  left  foot,  has  been  supposed  to  add 
to  other  predisposing  tendencies.  The  veins  of  the  cord,  in  any  case, 
would  seem  to  be  in  a  position  ready  to  become  overdistended,  as  they 
lie  loose  and  dependent  in  the  scrotum,  and  then  pass  through  the 
comparatively  narrow  inguinal  canal.  The  position  of  the  sigmoid 
flexure  of  the  colon,  on  the  left  side,  so  often  distended  by  fecal  ac- 
cumulation, is  also  believed  greatly  to  assist  in  the  formation  of  left 
varicocele,  which  is  always  worse  during  obstinate  constipation.  In 
the  female,  the  ovarian  veins  are  rarely  found  varicose,  except  in  the 
left  side.  Sir  Astley  Cooper  never  saw  it  on  the  right ;  the  sigmoid 
flexure  seems  at  fault.  Pressure  upon  the  veins  at  the  groin,  abdomi- 
nal tumors,  etc.,  assist  in  causing  varicocele.  Sometimes,  during  sud- 
den effort,  varicocele  appears  at  once,  and  .increases  rapidly ;  occa- 
sionally it  occurs  acutely  shortly  after  orchitis.  Pott  *  has  recorded 
three  cases  where,  after  fatigue,  local  injury,  and  cold,  sudden  pain 
in  the  back  set  in,  followed,  in  a  few  days,  by  relief  from  the  pain,  and 
an  acute  varicocele,  which  in  its  turn  was  succeeded  after  some  days 
by  complete  wasting  of  the  affected  testis,  in  one  case  of  both.  Prob- 
ably, in  these  cases,  there  was  some  inflammatory  condition  obliterating 
the  veins  above.  * 

I  have  seen  a  number  of  cases  of  acute  varicocele  following  an  effort — 
straining  of  some  sort — or  coming  on  spontaneously.  I  have  never  seen 
it  terminate  otherwise  than  in  recovery,  under  a  suspensory  bandage,  a 

*  Quoted  by  Curling. 


452  DISEASES  OF   TUE   CORD. 

mild  anodyne  and  a  laxative.  I  have  seen  it  last  a  nnmber  of  weeks, 
and  occasionally  leave  slight  permanent  enlargement  of  the  veins  of 
the  cord  behind. 

Si/nijjtom/<. — Excoi)t  in  acute  cases,  such  as  tliose  just  detailed,  vari- 
cocele comes  on  gradually,  and  is  discovered  by  accident.  The  amount 
of  pain  complained  of  is  very  variable  ;  a  very  large  varicocele  is  often 
attended  by  absolutely  no  pain,  while  a  very  slight  enlargement  of  the 
veins  may  give  rise  to  considerable  uneasiness,  extending  up  the  back 
and  down  the  thigh,  perhai).s  amounting  to  neuralgia  of  the  testis. 
Landouzy  has  noticed  that  the  symptoms  are  markedly  relieved  during 
and  immediately  after  coition,  but  become  worse  on  the  following  day. 

In  a  full-formed  varicocele  the  vessels  are  elongated,  their  valves 
broken  down,  their  Avails  alfected  by  fatty  atrophy,  and  thickened,  as 
is  also  the  surrounding  connective  tissue.  The  mass  fills  up  one  side 
of  the  scrotum,  perhaps  encroaches  on  the  other ;  its  shajje  is  some- 
what pyriform  ;  the  loops  of  A^eius  often  hang  below  the  testicle.  The 
mass  feels  soft,  like  a  bunch  of  earth-worms  ;  there  may  be  j^hlebolites 
in  the  veins.  The  veins  of  the  testicle,  also  between  the  tunica  vaginalis 
and  the  tunica  albuginea,  are  in  bad  cases  varicose.  The  scrotal  veins 
may  be  similarly  affected.  The  scrotum  is  thin  and  relaxed,  the  dartos 
powerless ;  sometimes  the  integument  is  so  thin  that  the  blue  color 
of  the  blood  in  the  veins  of  the  cord  is  visible.  In  long-standing  cases 
of  severe  varicocele  the  circulation  of  the  testis  is  liable  to  be  interfered 
with  to  such  an  extent  as  to  cause  the  gradual  atrophy  of  the  organ,  a 
result  in  no  way  due,  as  has  been  intimated,  to  the  weight  of  the  mass 
of  veins.  The  only  general  symptoms  in  varicocele  besides  pain  are 
those  of  hypochondria  and  defective  morale,  so  common  in  all  affections 
of  the  genital  organs. 

Diagnosis. — There  is  perhaps  no  disease  less  liable  to  be  mistaken 
than  varicocele  ;  the  wormy  feel  and  i^eculiar  look  of  a  cord  surrounded 
by  large  tortuous  veins  are  h.ardly  to  be  confounded  with  anything  else, 
unless,  possibly,  omental  hernia.  A  simple  test,  however,  removes  all 
doubt.  If  the  patient  lie  down,  the  whole  swelling  may  be  readily 
reduced.  The  fingers  are  now  placed  at  the  abdominal  ring,  and  the 
patient  is  told  to  rise  ;  hernia  will  be  retained,  the  swelling  of  varico- 
cele will  return,  the  vessels  filling  from  below  upward.  If  the  pressure 
at  the  ring  be  strong  enough  to  compress  the  arteries  as  well  as  the 
veins,  the  tumor  will  not  reappear.  Varicocele  complicated  by  large 
hydrocele,  or  by  hernia,  is  more  difficult  of  diagnosis. 

Treatment. — If  varicocele  be  small  and  the  symptoms  to  which  it 
gives  rise  inconsiderable,  the  palliative  treatment  already  recommended 
for  simple  cases  will  suffice.  Varicocele  never  compromises  life,  rarely 
deteriorates  health,  and,  when  it  is  sinijily  mechanically  incouA^onient, 
to  a  moderate  extent  it  should  be  overcome  by  mechanical  means.  All 
the  operations  proposed  for  varicocele  up  to  a  very  recent  date  have 


VARICOCELE— TREATMENT.  453 

been  more  or  less  formidable,  and  have  entailed  possible  fatal  conse- 
quences. To  offer  such  an  alternative  to  a  patient  moderately  afflicted 
was  a  serious  matter.  Dr.  Van  Buren  during  his  lifetime  was  opposed 
to  any  operation  for  varicocele  except  in  extreme  cases.  During  my 
twenty  years  of  association  with  him  I  can  only  recall  three  cases  of 
varicocele  operated  on,  one  by  curtailing  the  scrotum,  one  by  silver 
wire,  one  by  the  antiseptic  open  operation.  Each  of  these  operations 
confined  the  patient  to  bed  several  weeks. 

Since  perfecting  the  new  operation  which  I  have  recently  advo- 
cated,* namely,  the  subcutaneous  use  of  silk,  I  have  operated  upon  a 
great  number  of  cases.  No  patient  has  been  detained  in  bed  more 
than  ten  days,  many  not  more  than  five,  one  only  forty-eight  hours. 
No  accident  has  happened.  The  first  (catgut)  cases  did  not  get  well. 
Catgut  does  not  answer.  The  last  (silk)  cases  all  got  permanently 
well.  I  have  had  no  abscess,  only  the  escape  of  a  little  serum  in  two 
cases,  possibly  a  little  sero-pus  in  one  which  I  did  not  personally  at- 
tend. I  now  look  upon  the  operation  as  one  of  the  smallest  impor- 
tance, and  one  capable  of  yielding  such  marked  benefit  that  I  do  not 
hesitate  to  recommend  it  in  any  case  of  any  material  varicocele  which 
yields  discomforting  symptoms. 

I  once  saw  atrophy  of  the  testicle  follow  ligature  of  the  veins  at  the 
hands  of  an  excellent  surgeon.  I  have  never  seen  any  approach  to  this 
catastrophe  when  all  the  veins  on  both  sides  of  the  vas  deferens  were 
ligated  by  the  method  I  am  about  to  detail.  That  atrophy  may  not 
come  on  if  all  the  veins  are  tied  up  I  am  not  able  to  affirm  ;  but,  if  all 
the  large  veins  are  selected  out  and  ligated  in  two  masses,  one  on  each 
side  of  the  vas  deferens,  atrophy  does  not,  in  my  experience,  come  on. 
I  generally  apply  only  one  ligature  high  up  ;  I  have  frequently  also 
applied  another  on  the  other  side  of  the  vas  deferens  or  posteriorly ; 
sometimes  I  apply  two  on  the  same,  the  outer,  side  of  the  vas  deferens, 
one  high  up,  the  other  near  the  globus  major.  I  think  it,  therefore, 
only  necessary  to  describe  two  operations  for  varicocele  :  (1)  the  simple 
subcutaneous  ligature  ;  (2)  the  curtailment  of  the  scrotum,  applicable 
to  cases  in  which  the  scrotal  tissues  are  very  long  and  loose,  and  in 
which  the  scrotal  veins  are  also  varicose. 

Subcutaneous  ligature  of  the  vessels  for  varicocele  has  been  prac- 
ticed for  many  years,  silver  wire,  silk  over  an  outside  spring  or  button, 
or  rubber  ring  being  commonly  used,  or  the  elastic  ligature.  Finally, 
catgut  came  to  be  employed,  being  cut  short  and  left  in.  This  served 
admirably  so  far  as  suppuration  was  concerned,  but  the  catgut  did  not 
remain  long  enough  in  place,  and  the  vessels  resumed  their  patulency 
generally,  making  the  operation  a  failure.  Who  first  used  silk  in 
subcutaneous  ligature  I  know  not.     Ogston  f  used  it  in  1878.     E. 

*  "  New  York  Medical  Kecord,"  Feb.  20,  1886,  Sept.  18,  1886,  and  Nov.  26,  ISSY. 
+  "  Annals  of  Surgery,"  August,  1886. 


454  DISEASES  OF  THE   CORD. 

Barker*  reports  two  cases  in  which  he  used  silk,  passing  it  by  means 
of  a  puncture  made  with  a  knife.  I  eni])loYod  silk  for  te  first  timeh 
in  April,  1880,  not  knowing  at  that  time  that  it  had  been  used  before. 
Since  that  date  I  have  used  nothing  else,  and  I  have  nothing  to  regret, 
nothing  to  desire.  I  liave  prepared  the  silk — the  common  twisted  silk, 
of  good  size,  so  strong  that  it  can  not  be  broken  by  the  power  of  my 
hands — in  various  ways.  Recently  I  simply  boil  it  for  a  few  minutes 
to  purify  it  and  get  the  kinks  out,  and  put  it  into  a  bottle  containing 
pure  alcohol.  It  keeps  indefinitely,  and  is  always  ready  for  use  with- 
out further  preparation. 

I  have  devised  and  used  no  less  than  six  dilierent  needles  for  facili- 
tating the  operation,  but  of  late  have  come  to  use  a  modification  of 
Eeverdin's  needle.  The  needle,  as  modified  (Fig.  Ill),  is  simply  a 
straight  needle  in  a  handle.     By  a  mechanism  in  the  handle  the  eye 


Fig.  111. 

of  the  needle  is  opened  and  shut,  and  by  a  spiral  spring  which  I  have 
applied  the  eye  is  kept  permanently  closed,  so  that,  while  manipulating 
the  handle,  the  eye  can  not  be  opened,  as  may  and  occasionally  does 
happen  in  the  original  Eeverdin  needle,  during  careless  handling. 

Tlie  Operation. — The  scrotum  is  washed  in  a  bichloride  solution  of 
1  in  1,000.  The  patient  stands  beside  the  bed,  so  that,  if  he  becomes 
faint,  as  he  often  does  after  the  puncture,  he  may  be  at  once  placed 
upon  his  back  in  bed  and  the  operation  continued  in  that  position. 
The  distended  veins  are  separated  by  manipulation  fi'om  the  vas  def- 
erens, which  can  be  easily  felt  among  the  elements  of  the  cord,  and 
are  moved  toward  the  outer  side  of  the  scrotum.  The  needle,  taken 
from  the  bichloride  solution  and  armed  with  one  strand  of  silk,  is 
made  to  transfix  the  scrotum  between  the  veins  and  the  vas  deferens. 
"When  the  eye  of  the  needle  emerges,  the  silk  is  drawn  through  with  a 
tenaculum  and  disengaged  from  the  eye  of  the  needle.  Now  the 
punctured  scrotum  is  traversed  independently  by  the  needle  and  the 
one  strand  of  silk.  The  scrotum  is  again  washed  in  the  bichloride 
solution,  and  the  needle  withdrawn  partly  until  it  clears  the  veins, 
but  it  is  not  withdrawn  out  of  the  point  of  anterior  puncture  in  the 
scrotum.  The  veins  are  now  allowed  to  rejoin  the  vas  deferens,  and 
the  point  of  the  needle  is  again  advanced  upon  the  outer  side  under 
the  dartos,  and  made  to  emerge  posteriorly  at  the  exact  point  out  of 
which  the  silk  is  protruding.  The  eye  of  the  needle  is  now  opened, 
the  silk  placed  in  it,  and  the  instrument  entirely  withdrawn,  carrying 
the  silk  with  it.  The  scrotum  is  again  washed.  A  few  hairs  are 
plucked  away  from  the  posterior  point  of  puncture  in  the  scrotum, 

*  "Lancet,"  September  30,  1882,  p.  521. 


VARICOCELE— TREATMENT.  455 

and,  the  anterior  ends  being  firmly  held,  the  scrotum,  is  pulled  away 
so  that  the  shred  of  dartos  included  in  tlie  loop  at  the  posterior  punct- 
ure may  be  pulled  free  from  the  integument.  Now  a  few  more  hairs 
are  plucked  out  at  the  anterior  point  of  puncture,  that  they  may  not 
be  tied  in,  and  the  silk  is  forcibly  tied.  I  make  a  triple  knot  for 
security,  cut  the  ends  short,  and  let  the  knot  sink  into  the  scrotum. 

No  bleeding  occurs.  Any  drop  of  oozing  may  be  covered  at  the 
punctured  points  with  iodoform  or  iodol.  The  dressing  is  simply  a 
little  cotton  and  a  suspending  sling. 

If  other  veins  are  to  be  ligated  on  the  other  side  of  the  vas  deferens, 
the  punctures  should  be  made  during  the  erect  position  of  the  patient. 
The  washing  and  final  ligation  may  all  be  done  after  the  patient  lies 
down. 

An  anodyne  is  usually  unnecessary.  I  rarely  give  any  medicine 
except  a  laxative  on  the  third  day.  Some  pain  and  swelling  follow. 
As  soon  as  the  patient  can  stand  erect  without  considerable  pain,  he 
is  allowed  to  go  about. 

The  swelling  gradually  subsides.  The  hard  spot  at  the  ligated 
point  remains,  certainly  for  a  year,  possibly  longer.  If  all  the  affected 
veins  are  ligated,  cure  is  certain.  I  have  as  yet  seen  no  complication. 
If  pus  should  form,  which  I  hardly  think  possible  if  proper  care  has 
been  used,  it  must  be  let  out  by  incision  and  treated  according  to  its 
necessity. 

Ablation  of  the  scrotum,  when  called  for,  may  be  performed  by  cut- 
ting away  the  redundant  portion  with  curved  scissors,  or  upon  one 
of  the  numerous  clamps  which  have  been  devised  for  the  purpose.* 
Anaesthesia  is  necessary.  The  excess  of  scrotum  is  to  be  taken  up  in 
the  line  of  the  raphe,  and  parallel  to  it.  All  bleeding  points  should  be 
carefully  ligated  with  catgut.  If  this  operation  is  performed,  it  is 
better  to  dissect  out  the  enlarged  veins,  to  ligate  them  at  each  end,  and 
cut  away  the  middle  portion.  Finally,  the  edges  of  the  wound  are  to 
be  accurately  coapted  and  closely  sutured,  the  wound  drained  and 
dressed  antiseptically. 


CHAPTER  XXYIII. 

DISEASE  OF  TEE   VAS  DEFERENS  AND  SEMINAL    VESICLES. 

Anatomy.— Inflammation,  acute  and  chronic. 

The  excretory  duct  of  the  testicle  commences  at  the  tail  of  the 
epididymis,  forms  one  of  the  principal  constituents  of  the  cord,  passes 
through  the  inguinal  canal,  curves  down  into  the  cavity  of  the  pelvis, 

*  The  clamp  of  Henry,  of  New  York,  is  an  admirable  one. 


456        DISEASE  OF  THE  YAS  DEFEREXS  AND  SEMINAL  VESICLES. 

skirts  the  base  of  tlie  bladder,  and,  joining  with  the  duct  from  the 
seminal  vesicle,  terminates  as  tlie  ejaculatorj  duct  on  one  side  of  the 
summit  of  tlie  veru  montanum  in  the  prostatic  sinus.  The  canal  is 
nearly  two  feet  long,  from  a  line  to  a  line  and  a  half  in  diameter. 
Four  fifths  of  its  structure  is  muscular.  It  is  very  dense  and  hard, 
and  feels  like  a  whip-cord  when  rolled  between  the  fingers.  Its  outer 
coat  contains  condensed  connective  tissue,  elastic  libers,  vessels,  nerves, 
and  a  little  longitudinal  unstriped  muscle.  The  middle  tunic  is  mus- 
cular, its  external  and  a  few  internal  fibers  run  longitudinally,  the 
middle  fibers  are  circular.  The  internal  tunic  is  mucous,  provided 
at  its  commencement  with  ciliated  epithelium.  This  membrane  lies 
in  longitudinal  folds,  more  or  less  reticulated,  particularly  in  that  part 
of  the  canal  lying  within  the  brim  of  the  true  pelvis.  Here  the  cavity 
of  the  canal  usually  enlarges  into  a  sort  of  reservoir,  while  the  sides  are 
furnished  with  pouches  and  diverticula,  recalling  the  appearance  of 
the  seminal  vesicles.  The  dilated  portion  of  the  canal  is  well  supplied 
with  simple  sacculated  glands.  They  are  filled  with  numerous  yellow- 
ish-brown granulations  which  give  a  jDCCuliar  color  to  the  mucus  of 
the  part. 

The  vas  deferens  may  end  in  a  blind  extremity  or  be  deficient  when 
there  is  no  testis.  It  is  not  often  diseased.  It  may  become  inflamed 
in  connection  with  gonorrhoea  leading  to  abscess.  It  participates  in 
tubercular  and  pseudo-tubercular  disease  of  the  epididymis.  Portions 
of  its  structure  so  diseased  may  soften  and  form  abscesses,  which  break 
externally,  or  perhaps  internally,  followed  by  a  slight  discharge  of 
bloody  pus  from  the  urethra,  and  perhaps  leading  to  occlusion  of  the 
canal  during  cicatrization. 


DISEASES    OF    THE    SEMINAL    VESICLE. 

The  seminal  vesicle  is  a  reservoir  connected  with  the  vas  deferens. 
Its  function  is  to  collect  seminal  fluid,  dilute  it  by  an  admixture  with 
its  own  secretion,  and  hold  it  ready  for  use.  The  vesicle,  from  one 
to  two  and  a  half  inches  long  by  half  an  inch  broad,  lies  at  the  outer 
side  of  its  own  vas  deferens,  its  apex  imbedded  in  the  prostate,  its 
fundus  diverging  from  its  fellow  of  the  other  side,  so  as  to  skirt  that 
portion  of  the  bladder  which  usually  lies  in  contact  with  the  rectum, 
and  corresponds  to  the  trigone  within.  The  vesicle  is  simply  a  tube 
so  rolled  up  and  doubled  upon  itself  that  its  blind  extremity  nearly 
corresponds  in  position  to  its  neck.  When  unrolled,  the  tube  meas- 
ures from  four  to  eight  inches.  It  is  plentifully  supplied  with  diver- 
ticula and  branched  pouches,  so  as  to  present  on  section  the  appearance 
of  a  cellular  cavity.  At  the  neck  a  short  constricted  canal  joins  the 
vas  deferens  at  an  acute  angle,  to  form  the  ejaculatory  duct.  The 
minute  structure  of  the  walls  of  the  seminal  vesicles  is  identical  with 


THE  SEMINAL  VESICLE.  457 

that  of  the  vas  deferens.  The  convolutions  of  the  tube  arc  united  by 
connective  tissue,  containing  a  large  amount  of  unstriped  muscle. 
After  surrounding  the  vesicle,  this  tissue  crosses  over  and  envelops 
the  vesicle  of  the  other  side.  The  whole  is  known  as  the  posterior 
aponeurosis  of  the  prostate. 

The  arteries  of  the  seminal  vesicles  come  from  the  inferior  vesical 
and  middle  hsemorrhoidal.  The  veins  join  the  plexus  on  the  sides  of 
the  bladder.  The  lymphatics  go  to  the  j)elvic  ganglia.  The  fluid  of 
the  vesicles  is  albuminous,  and  contains  many  yellowish  bodies  and 
masses  of  spermatozoa.  The  vesicle  discharges  by  contraction  of  its 
own  wall,  of  the  muscular  membrane  surrounding  it,  and  of  the  leva- 
tor-ani  muscle.  An  acquaintance  with  the  position  of  the  seminal 
vesicles  is  essential  to  the  performance  of  puncture  of  the  bladder  by 
the  rectum,  or  of  the  retro-vesical  operation  for  stone.  When  the 
bladder  is  full,  the  vesicles  are  pressed  apart,  and  it  would  be  difficult 
to  wound  them.  Cruveilhier,*  however,  speaks  of  a  specimen,  pre- 
sented to  the  Anatomical  Society  by  Deville,  where  the  two  vesicles 
were  confounded  in  a  single  median  pouch  with  two  difEerential  canals. 
This  anomaly  is  very  rare. 

Ateophy  of  the  seminal  vesicle  follows  atrophy  of  the  correspond- 
ing testicle  or  its  ablation.  The  vesicle  is  also  absent  or  defective 
where  there  is  no  testicle  of  the  same  side.  The  vesicles  are  jiartly 
imbedded  in  prostatic  hypertrophy,  and  become  involved  in  prostatic 
cancer. 

The  only  morbid  conditions  of  these  organs,  however,  commonly 
met  with  in  practice,  are  inflammatory  and  tubercular  disease.  Con- 
gestion of  the  prostatic  sinus,  in  individuals  given  to  venereal  excess, 
especially  if  they  be  weakly,  leads  to  a  lack  of  tone  in  the  ejaculatory 
ducts,  so  that  they  remain  more  or  less  patulous.  Under  these  cir- 
cumstances involuntary  emissions  are  frequent,  and  a  flow  of  semen 
may  occur  on  urination,  or  during  efforts  at  straining,  particularly  at 
stool,  if  there  be  constipation.  The  pressure  of  the  levator  ani  and  of 
the  fecal  mass  upon  the  seminal  vesicles  forces  their  contents  through 
the  relaxed  ducts.  Reliquet  f  has  recorded  a  case  of  impaction  of  the 
left  ejaculatory  canal  by  sympexions  (the  little,  soft,  yellowish,  striated 
bodies,  breaking  with  a  peculiar  fracture,  and  always  found  in  the  semi- 
nal vesicles.  Sometimes  large  sympexions  entrap  in  their  structure 
the  true  spermatic  elements).  Eeliquet  is  inclined  to  ascribe  to  these 
sympexions  the  pain  which  some  people  feel  at  certain  times  during 
the  venereal  orgasm.  Eeliquet  calls  his  case  spermatic  colic.  A  man 
of  thirty-five,  who  had  had  pain  on  urinating  a  year  before  without 
obvious  cause,  and  who  during  straining  at  stool  had  often  voided  a 
thick  white  fluid  by  the  urethra,  complained  for  two  months  of  pain 
during  the  venereal  act,  followed  by  pain  on  urination,  with  spasm, 

*  Op.  cit.,  p.  375.  f  Reprint  from  "Gaz.  des  Hop.,"  1874. 


458        DISEASE  OF  THE  VAS  DEFERENS  AND  SEMINAL  VESICLES. 

pain  on  standing  and  walking,  great  pain  during  an  action  of  the 
bowels,  and  excessive  distress  on  erection.  The  urine  contained 
blood.  The  left  seminal  vesicle  was  hard,  swollen,  painful  upon  rectal 
touch.  Eeliquet  made  an  exploration  with  a  lithotrite.  During 
Avithdrawal  .of  the  instrument  there  was  violent  spasm,  after  which 
the  patient  voided  some  water  which  had  been  previously  injected 
into  the  bladder,  and  ])assed  forty  soft,  dead-white  bodies,  varying 
from  the  size  of  the  head  of  a  pin  to  that  of  a  small  bean.  These 
bodies  were  declared  by  Robin  to  be  sympexions.  The  patient's  symp- 
toms immediately  improved,  and  an  examination  of  the  seminal  vesi- 
cle showed  that  it  was  no  longer  distended.  Keliquet  *  later  pub- 
lished a  somewhat  similar  case,  cured  by  milking  out  the  seminal  vesi- 
cle several  times  with  the  finger. 

Inflammatiox  of  the  Seminal  Vesicles. — This  affection  is  rare. 
It  is  usually  unilateral,  and  is  due  to  extension  of  inflammation  from 
the  prostatic  sinus,  gonorrhojal  or  otherwise. 

Symjitoms. — Digital  examination  by  the  rectum  reveals  a  hot,  sen- 
sitive, oval  swelling  behind  the  prostate,  in  the  position  of  the  seminal 
vesicle,  perhaps  on  both  sides.  The  size  is  double,  or  more,  that  of 
the  normal  vesicle.  The  surface  is  hard  and  uneven,  or  fluctuating. 
There  is  complaint  of  a  continued,  heavy  pressing  (perhaps  pricking) 
pain  in  the  rectum,  low  down,  shooting  toward  the  sacrum.  The  pain 
often  involves  the  testicle,  which  is  sensitive  and  turgcscent.  Urina- 
tion may  be  difficult  on  account  of  the  pain,  which  is  increased  by 
rectal  examination,  and  greatly  aggravated  during  defecation.  I  have 
seen  retention  of  urine  from  this  cause,  and  many  cases  in  which  more 
or  less  persistent  spasm  of  the  deep  urethral  cut-off  group  of  muscles 
was  due  to  it.  Verneuil  f  reports  an  excellent  example  of  this  compli- 
cation. There  may  be  frequent  painful  erection,  perhaps  priapism. 
Any  attempts  at  sexual  intercourse  greatly  aggravate  the  pain.  There 
may  be  involuntary  painful  nocturnal  emissions  of  semen  mixed  with 
pus  and  streaked  with  blood,  and  a  constant  viscid  purulent  discharge 
from  the  urethra,  also  colored  or  streaked  with  blood,  and  containing 
spermatozoa. 

These  symptoms  may  subside  after  a  few  days  or  persist  in  a  chronic 
form  indefinitely,  there  being  a  gleety  discharge  containing  seminal 
elements,  and  more  or  less  sexual  irritability.  This  may  wear  the 
patient  out,  leading  to  serious  melancholy  or  hypochondria.  The 
symptoms,  however,  may  gradually  improve  with  the  general  health 
up  to  complete  recovery.  If  the  inflammation  reach  a  high  grade,  the 
duct  of  the  vesicle  becomes  obliterated,  abscess  forms  and  discharges 
into  the  urethra  or  rectum,  leaving  fistula  behind.  After  such  abscess 
and  fistula,  the  vesicle  sometimes  gradually  atrophies,  and  with  it  the 

*  "Gaz.  dea  Hop.,"  1879,  p.  891. 

f  Referred  to  by  Sebeaux,  "  Contractures  du  Col  de  la  Vessie,"  Paris,  18Y6,  p.  40. 


TUBERCULAR  DISEASE  OF  THE  SEMINAL  VESICLES,  459 

vas  deferens  and  epididymis  of  the  same  side  are  very  apt  to  dwindle 
away.  Finally,  the  chronic  inflammation,  under  the  influence  of  gen- 
eral impaired  vitality,  may  lead  to  thickening  of  the  walls  of  the  vesicle, 
cheesy  degeneration  with  softening,  abscess,  fistula,  calcification,  etc. 
Inflammation  of  the  vesicle  may  lead  to  peritonitis  (Peter,  Godard, 
Faucon).* 

Treatment. — The  treatment  of  acute  inflammation  of  the  seminal 
vesicles  is  absolute  rest  in  bed,  with  opiate  suppositories,  and  perhaps 
camphor  and  lupulin,  to  modify  erection.  This,  with  local  application 
of  heat,  warm  enemata,  and  an  early  ojDcning  through  the  rectum 
of  any  abscess  that  may  form,  constitutes  the  treatment.  Any  chronic 
inflammation,  with  gleety  discharge,  which  may  be  left  behind,  must 
be  combated  with  general  hygiene  and  tonics. 

Hydrocele  of  the  seminal  vesicle  yielding  an  enormous  amount  of 
fluid  on  tapping  is  reported  by  N.  R.  Smith,  f  of  Baltimore.  It  was 
cured  by  a  second  tapping.  Heinemann  J  showed  to  the  New  York 
Society  of  German  Physicians  a  specimen  of  double  cystic  disease  of  the 
seminal  vesicles.  The  vesicles  were  about  three  times  the  normal  size. 
He  had  found  records  of  four  similar  cases,  Pitha  and  Billroth,  Eng- 
lisch.  Mason,  and  Peabody. 

Tubercular  Disease  of  the  Seminal  Vesicles. — This  affection  may 
occur  without  any  antecedent  local  inflammation,  or  may  follow 
chronic  inflammatory  disease.  Cheesy,  yellow  masses  of  deposit  occur, 
which  tend  to  soften  centrally.  It  rarely  is  seen,  except  in  connection 
with  more  advanced  disease  of  a  similar  character  in  the  prostate, 
epididymis,  kidney,  or  bladder.  The  vesicle  is  often  involved  syn- 
chronously with  the  vas  deferens,  and  may  be  felt  through  the  rectum, 
hard,  knobbed,  irregular,  perhaps  insensitive  to  pressure,  perhaps 
tender,  more  or  less  inflamed,  and  with  softened  spots.  If  abscess 
form,  it  discharges  into  the  rectum,  or  perhaps  into  the  prostatic 
sinus,  leaving  a  cavity  in  connection  with  the  latter,  which  furnishes 
a  constant  supply  of  gleety  material  such  as  escapes  from  the  urethra 
in  tubercular  prostatitis. 

Treat7nent. — Local  treatment  is  symptomatic.  The  general  meas- 
ures, which  may  be  curative  if  conscientiously  followed  out,  have  been 
given  in  the  sections  upon  treatment  of  the  same  morbid  condition  of 
the  prostate,  bladder,  and  epididymis. 

*  "Archiv.  Gen.,"  October,  1877,  p.  385. 

f  London  "Lancet,"  October,  1872. 

t  "New  York  Medical  Journal,"  March,  1880, 


PAET    II. 
CHANCROID  AND   SYPHILIS. 


CHAPTER  I. 
CHANCROID. 

Definition.— Transmissibility  to  Animals.— Cause  of  Chancroid.— Indefinite  Inoculahility.— Relative 
Frequency.- Methods  of  Contagion. — Explanation  of  Apparent  Long  Period  of  Incubation.— 
Situation  of  Chancroid. — Symptoms.— Course. — Character  of  Scar. — Variation  of  Cluincroid 
from  Type,  in  Initial  Form,  in  Shape,  in  Number,  in  Size,  in  Duration,  in  Pain,  in  Condition  of 
Base,  in  Course  (Relapse).— Complication  by  Vegetations,  by  Syphilitic  Chancre,  by  Inflamma- 
tion, by  Gangrene  and  Gangrenous  Phagedena,  by  Pultaceous  Phagedena,  by  Bubo,  by  Lyni- 
phitis.— Diagnosis  of  Chancroid.— Prognosis. 

Custom  in  America  has  adopted  the  name  '*  chancroid  "  (originated 
by  Clerc)  to  express  that  form  of  contagious  venereal  ulcer  which  is 
not  accompanied  by  any  constitutional  syphilitic  infection.  It  is 
"widely  known  also  as  soft  chancre,  or  simple  chancre  ;  but,  of  the 
many  terms,  perhaps  chancroid  is  the  least  liable  to  lead  to  ambiguity, 
and  it  is  essentially  appropriate,  as  signifying  a  disease  which,  while 
it  is  like  a  (syphilitic)  chancre,  is  still,  in  fact,  widely  different  from 
it.  For  true  chancre,  the  initial  lesion  of  syphilis,  the  term  syphilitic 
chancre  will  be  adopted. 

Chancroid  is  a  local  virulent  ulcer,  never  the  starting-point  of 
syphilis,  always  due  to  inoculation  of  pus  derived  from  a  similar 
ulcer.     Its  own  secretions  are  freely  auto-inoculablc. 

Of  the  three  distinct  venereal  di.seases — gonorrho?a,  chancroid,  syi^hi- 
lis — gonorrhoea  is,  strictly  speaking,  the  most  venereal,  being  practi- 
cally never  acquired  except  in  sexual  intercourse.  Chancroid,  equally 
virulent,  is  less  venereal,  and  recognizes  many  methods  of  propagation 
besides  sexual  congress  ;  while  syphilis  is  of  all  the  least  virulent  (in 
the  sense  of  the  facility  with  which  it  may  be  acquired),  and  the  least 
venereal,  as  will  be  shown  when  treating  that  subject. 


CAUSE.  4f;l 

Chancroid  is  an  affection  only  perpetuated  by  contagion,  but  for 
this  sexual  intercourse  is  not  essential.  Wherever  upon  the  human 
body  a  chancroid  is  found,  there,  it  may  be  positively  affirmed,  pus 
from  some  other  chancroid  has  been  deposited  under  conditions  favor- 
able for  its  absorption.  No  amount  of  sexual  excess,  no  degree  of 
uncleanliness,  no  irritation,  traumatic  or  chemical,  however  prolonged, 
no  simple  or  poisonous  ulceration  from  other  specific  source  (syphilis, 
cancer,  glanders,  etc.),  nothing,  in  short,  can  produce  chancroid  ex- 
cept chancroid  (chancroidal  bubo  of  course  included).  The  appar- 
ent exceptions  adduced  by  Pick,  Lee,  Wigglesworth,  Kraus,  Eeder, 
L.  Vidal,  Kaposi,  Bidenkap,  and  others,  showing  auto-inoculable  pus 
derived  from  sources  not  chancroidal,  do  not  negative  the  above 
proposition.*  Of  syphilis  this  much  can  not  be  said  ;  its  methods  of 
propagation  are  far  more  numerous  than  simple  local  contagion. 

Chancroid,  furthermore,  is  transmissible  to  animals.  Some  experi- 
menters have  obtained  only  negative  results  ;  others  have  been  success- 
ful, showing  that,  although  animals  may  receive  the  disease,  they  do 
so  imperfectly  and  often  not  at  all.  Chancroid  developed  on  animals 
heals  quickly.  Auzias  Turenne,  in  1844,  first  successfully  inoculated 
monkeys,  rabbits,  cats,  and  dogs  with  chancroid.  Eobert  de  Weltz, 
in  1850,  inoculated  his  own  arm  four  times  with  pus  taken  from 
chancroid  artificially  developed  ujDon  a  cat  and  a  monkey  :  all  four 
inoculations  took  and  produced  the  characteristic  ulcer.  Diday,  in 
1851,  from  a  chanci-oid  which  had  been  produced  by  inoculation  upon 
the  ear  of  a  cat,  inoculated  himself  successfully  on  the  jjenis.  The 
ulcer  became  phagedenic  and  was  attended  by  supjiurating  bubo. 
Eicordi  brought  about  a  chancroidal  bubo  m  a  rabbit,  which  he  had 
inoculated  with  pus  from  the  chancroid  of  another  rabbit. 

It  was  in  connection  with  experiments  of  this  order  that  Auzias 
Turenne  invented  the  term  "syphilization,"  since  he  found  that  rein- 
oculation  of  chancroid  pus  upon  animals  resulted  in  a  less  and  less 
perfect  ulcer  each  time,  until  no  effect  was  produced  at  all.  f  As 
Auzias  Turenne  recognized  no  difference  between  chancroid  and  syphi- 
lis, he  supposed  that  this  immunity  of  the  skin  of  animals  to  chan- 
croid pus  indicated  that  they  were  saturated  with  syphilis,  ''  syphi- 
lized,"  and  exempt  from  all  further  trouble  from  that  disease. 
Hence  the  term  syphilization,  which,  starting  in  a  misconception,  has 
been  perpetuated  even  to  our  day,  and  has  still  some  conscientious 
advocates. 

Cause. — As  already  stated,  the  cause  of  chancroid  is  unique.  It 
can  be  produced  only  by  the  contact  of  pus  from  a  similar  ulcer  upon 
some  portion  of  the  skin  or  mucous  membrane  under  conditions  favor- 

*  I  have  considered  this  subject  with  some  care  and  at  some  length  in  my  work  on 
"Venereal  Diseases,"  New  York,  William  "Wood  &  Co.,  1880,  p.  11  et  seq. 
f  Letter  to  the  Academy  of  Sciences,  1850,  quoted  by  RoUet. 


462  CHANCROID. 

able  for  ab?or]>tioii.  No  one  is  exempt.  The  bearer  of  a  chancroid 
is  just  as  liable  to  be  poisoned  by  the  pus  of  his  own  sore  as  is  a  per- 
fectly healthy  person.  Other  diseases  do  not  furnish  any  immunity.* 
Positive  results  are  obtained  by  inoculation  upon  patients  with  cancer, 
with  syphilis,  witli  scrofula,  with  elephantiasis,  and  a  previous  attack 
of  the  disease  does  not  insure  in  any  manner  against  succeeding  at- 
tacks. 

Eollet,f  following  Von  Roosbroeck's  lead,  has  demonstrated  by  ex- 
periment that  the  contagious  principle  resides  in  the  pus-corpuscles, 
and,  if  these  be  filtered  out,  all  inoculations  witli  the  remaining  fluid 
prove  negative.  What  this  contagious  principle  or  virus  is,  has  not 
yet  been  discovered.  Assertions  have  appeared  from  time  to  time 
(Donne,  Didicr,  Salisbury)  that  a  peculiar  parasite  has  been  discov- 
ered, now  animal,  now  vegetable,  which  was  the  essential  poisonous 
agent,  but  the  authors  of  all  such  theories  thus  far  have  failed  to  sub- 
stantiate their  claims,  and  it  still  remains  for  the  chemist  or  the  micro- 
scopist  to  demonstrate  in  exactly  w'hat  the  poison  of  chancroid  con- 
sists. Thus  far  the  pus  of  chancroid  is  identical,  under  all  tests,  with 
pus  from  any  other  ulcer.  By  its  poisonous  effects  alone  it  is  distin- 
guishable.    These  effects  may  be  studied  by  inoculation. 

Chancroidal  pus  preserves  its  poisonous  i^roperties  if  kept  cool  in 
tightly-corked  bottles.  Boeck  states  (oral  communication)  that  they 
are  in  the  habit  of  sending  it  from  the  hospitals  of  Christiania  into 
the  surrounding  country  for  purposes  of  "syi)hilization."  It  may  be 
frozen,  and  still  inoculable  when  thawed.  Boeck  believes  that  it  loses 
its  virulence  after  having  been  dried.  Dried  pus  certainly  sometimes 
fails  to  give  positive  results  when  remoistened,  but  this  can  not  be  re- 
lied upon,  as  Sperino  J  used  a  lancet  which  had  been  laid  aside  for 

■*  It  has  been  stated  that  chancroid  will  not  take  upon  a  patient  suffering  at  the  time 
from  acute  febrile  disease.  Dr.  Morrison-Fiset,  at  the  Charity  Hospital,  at  my  suggestion 
undertook  some  experiments.  They  were,  unfortunately,  interrupted  after  the  doctor  had 
inoculated  one  patient  three  times  upon  the  thigh — the  gentleman  in  charge  of  the  fever 
wards  being  fearful  lest  syphilis  should  be  introduced  among  his  patients.  The  one  case 
inoculated  was,  however,  carefully  studied  by  Dr.  5Iorrison-Fiset.  The  inoculations  were 
made  at  the  end  of  the  second  week  after  chill,  the  patient's  temperature  ranging  at 
103-104°  Fahr.  Boeck's  method  was  used,  and  three  punctures  made,  one  quarter  of  an 
inch  apart.  Two  of  the  punctures  took  perfectly,  although  the  process  of  ulceration  was 
very  slow.  On  the  thirteenth  day  pus  from  one  of  these  ulcers  was  inoculated  upon  a 
healthy  patient,  with  the  effect  of  producing  a  characteristic  chancroid.  The  ulcers  on 
the  leg  of  the  typhoid  patient  finally  became  confounded  in  a  single  ulceration  two  inches 
in  diameter,  which  was  dressed  with  iodoform,  and  on  the  patient's  discharge  from  the 
hospital,  convalescing,  after  a  sojourn  of  fifty-three  days,  the  ulcer  was  reduced  to  a 
diameter  of  one  inch,  and  was  healing.  The  ulcers  were  under  observation  after  inocula- 
tion forty-six  days.  The  evening  temperature  remained  near  104°  for  several  days  after 
inoculation. — Keyes. 

\  "Trait6  des  Maladies  v6ndriennes,"  Paris,  1866. 

X  "Studi  clinici  sul  Virus  sifilitico,"  Turin,  1863. 


INDEFINITE  INOCULATIBILITY.  4fj3 

seven  months,  upon  the  point  of  which  was  some  dried  chancroidal 
pus.  Three  punctures  were  made  with  this  lancet,  all  of  which  took. 
Heat,  however,  at  the  boiling-point,  destroys  the  activity  of  the  virus ; 
acids,  alkalies,  alcohol,  all  destroy  its  virulence  at  once,  and  decompo- 
sition is  fatal  to  it.  When  gangrene  attacks  a  chancroid,  the  sore  is 
no  longer  poisonous.  With  the  above  and  kindred  exceptions,  a  mix- 
ture of  chancroidal  pus  with  any  indifferent  menstruum  does  not  injure 
its  virulence ;  such  as  water,  urine,  saliva,  sweat,  mucus,  muco-pus, 
spermatic  fluid. 

As  to  the  amount  of  pus  required  to  effect  contagion,  probably  one 
microscopic  pus-corpuscle  is  sufficient.  The  smallest  possible  prick  of 
the  skin  to  which  the  pus  is  applied  will  produce  just  as  characteristic 
a  chancroid  as  will  the  bountiful  smearing  of  a  raw  surface  of  any  size. 
Puche  *  got  positive  results  by  inoculation  from  a  drop  of  pus  diluted 
with  half  a  glass  of  water,  Boeck  after  diluting  with  1,100  parts  of  other 
pus. 

The  poisonous  effect  of  chancroidal  pus  is  evinced  by  its  power 
of  rapidly  begetting  a  chancroid  whenever  it  is  brought  within  the 
reach  of  absorption,  by  a  removal  of  the  cuticle  or  external  layers  of 
epithelium  from  any  surface.  Inoculation  or  hetero-inoculation  signi- 
fies the  contact  of  this  pus  with  an  abraded  surface  of  any  individual 
other  than  the  one  who  furnishes  the  pus.  Auto-inoculation  signifies 
such  contact  upon  the  body  of  the  bearer  of  the  chancroid.  Evidently 
such  inoculation  may  be  the  result  of  accident  or  design. 

Chancroidal  poison  is  indefinitely  auto-inoculable.  Lindmann  in- 
oculated himself  2,700  times,  and  was  still  making  successful  auto- 
inoculations  when  last  reported  by  Fournier.  The  body  of  Auzias 
Turenne  is  said  to  have  been  found  covered  with  chancroid  scars  at 
his  death,  showing  that  he  did  not  shrink  from  practicing  his  pet 
theory,  "syphilization,"  f  upon  himself. 

By  the  process  of  syphiiization,  immunity  of  the  skin  to  the  poison 
is  obtained.  A  certain  pus  is  employed,  and  reinoculated  until  it  will 
no  longer  produce  a  pustule  ;  then  fresher  pus  from  some  other  younger 
chancroid,  until  it  also  fails ;  and  until,  finally,  no  inoculation  gives  a 
positive  result.  This  much  syphilizers  have  taught  us,  and  they  have 
also  taught  us  that  the  different  regions  of  the  body  are  susceptible  in 
a  different  degree  to  the  action  of  a  chancroidal  j)us  of  given  virulence  ; 
for,  after  the  chest  fails  to  take,  the  arms  may  still  be  inoculated  suc- 
cessfully ;  and,  finally,  when  the  arms  have  acquired  immunity,  the 
thighs  will  still  furnish  characteristic  results  upon  inoculation.     This 

*  Kicord,  "  Le9ons  sur  le  Chancre,"  Fournier. 

f  The  term  syphiiization  is  here  used  in  the  sense  first  given  to  it  by  Auzias  Turenne, 
but  it  must  be  understood  tliat,  in  accordance  with  the  views  advanced  in  this  treatise, 
the  term  is  essentially  incorrect,  as  the  virus  of  true  syphilis  is  entirely  distinct  from  that 
of  the  chancroid  ulcer. 


464  CDANCROID. 

immunity,  however,  obtained  by  frequent  and  continuous  irritation  of 
the  skin  with  numerous  chancroid  ulcers,  is  more  apparent  than  real, 
since  it  is  only  temporary  ;  for  after  the  skin  lias  had  a  rest  for  some 
months,  inoculations  often  again  give  a  positive  result  (Bocck,  oral 
communication). 

Hence  the  rule,  practically  true  :  an  individual  may  have  chancroid 
as  often  as  he  is  exi)osed  ;  there  is  no  limit  to  the  number  of  jiossible 
attacks. 

Frequency  of  Chaxcroid. —  Statistics,  which  vary  greatly  at 
the  hands  of  different  collectors,  only  show  in  a  general  way  that  in 
dispensaries  and  hospitals,  among  the  poor  and  dirty,  the  frequency 
of  chancroid  far  outranks  that  of  true  syphilitic  chancre,  while  private 
statistics  taken  from  otiice  practice  in  the  better  classes  demonstrate 
clearly  that  in  this  set  of  patients  the  true  syphilitic  chancre  is  more 
common  than  the  chancroid.  Puche's  ancient  figures  gave  eighty  per 
cent  to  chancroid  in  the  Midi  Hospital,  but  that  this  varies  greatly  is 
shown  byMauriar*  and  Ilorteloui^f  Fournier  J  first  clearly  called 
attention  to  the  general  relative  difference  between  the  cases  com- 
monly encountered  in  hosjoital  and  in  private  practice.  The  reasons 
for  this  singular  difference  of  figures  are  obvious.  The  lower  classes 
of  society  who  enter  hospitals  are  given  to  intemperance,  and  careless 
in  their  habits.  Furthermore,  they  are  poor,  and  consort  with  the 
lower  orders  of  prostitutes,  those  who  are  unable  to  care  for  themselves 
when  diseased,  but  must  continue  at  their  profession  to  gain  their 
daily  bread.  Most  of  these  also  are  old,  have  had  syphilitic  chancre 
and  contagious  secondary  lesions  in  their  youth,  and  are  therefore 
incapable  of  giving  syphilitic  chancre,  while  many  of  them  possess  old 
chronic  chancroid,  which  is  kept  from  getting  well  by  constant  local 
irritation,  and  which  forms  a  hot-bed  of  infection  for  all  who  approach. 
Old  prostitutes  get  used  to  the  idea  of  having  a  chancroid,  and  con- 
sider it  a  small  matter.  The  more  refined  and  wealthy  males  of  the 
upper  classes,  on  the  contrary,  are  careful  in  their  selection  of  females. 
They  seek  the  young  and  those  apparently  sound.  Young  prostitutes 
are  often  unaware  of  having  syphilitic  chancre  or  secondary  lesions  of 
the  vagina,  while  they  can  scarcely  be  ignorant  of  the  presence  of  the 
more  formidable-looking  chancroid  with  its  possibly  accompanying 
inflammatory  bubo,  and  fear  prompts  them  to  seek  medical  aid,  and 
give  up  their  profession  temporarily  in  the  latter  case,  while  they 
might  innocently  continue  it  in  the  former.  Furthermore,  none  of 
the  upper  classes  appear  at  hospitals,  and  few>of  the  lower  who  have 
syphilitic  chancre  (often  an  insignificant-looking  painless  lesion),  while 
they  run  in  all  haste  for  relief  for  the  painful,  angry-looking  chan- 

*  "  Raret6  actuelle  du  chancre  simple,"  Paris,  ISYC. 
f  "Ann.  de  Dermat.  et  de  Syph.,"  January,  1880,  p.  64. 
X  Art.  "  Chancre,"  "  Diet  de  Med.  et  de  Cliir.  prat." 


METHODS  OF  CONTAGION".  465 

croid.  Finally,  syphilitic  chancre  occurs  but  once  in  a  lifetime,  and 
rarely  lasts  long  ;  while  chancroid  may  be  acquired  an  indefinite  num- 
ber of  times,  and  may  possibly  in  certain  forms  last  a  number  of  years. 
Hence  the  rule  :  in  hospitals,  chancroid  far  outnumbers  syphilitic 
chancre.  The  same  holds  for  the  practice  of  the  young  surgeon,  or 
for  those  who  attend  the  poorer  classes  ;  while,  in  the  higher  walks  of 
life,  ulcerations  about  the  penis  will  be  mainly  herpes,  or  abrasions, 
or  balanitis,  syphilitic  chancre  next  in  frequency,  chancroid  least 
common. 

Methods  of  Coktagion. — Contagion  is  immediate,  i.  e.,  by  direct 
contact,  as  in  sexual  intercourse,  or  manipulation  of  chancroids  with 
fissures  or  abrasions  on  the  hand  ;  or  mediate,  i.  e.,  through  some 
intervening  agency,  as  by  carrying  the  poison  upon  the  fingers  in 
scratching,  and  thus  inoculating  some  abraded  surface.  The  "virus  is 
fixed  and  not  volatile,  and  actual  contact  with  the  pus  is  essential  to 
infection.  Contagion  takes  place  in  the  vast  majority  of  instances 
during  the  sexual  act,  but,  as  any  abraded  surface  upon  any  part  of 
the  body  is  capable  of  absorbing  the  virus,  cases  of  accidental,  mediate, 
or  immediate  contagion  occasionally  occur,  as  on  the  finger  of  the 
accoucheur.  Spontaneous  auto-inoculation  is  common,  especially 
where  the  virulent  pus  is  retained  between  two  tegumentary  surfaces 
lying  in  contact,  as  beneath  the  prepuce. 

Mediate  contagion  in  sexual  intercourse  is  possible.  Thus,  a  man 
with  a  long  prepuce,  but  no  abrasions,  may  carry  the  virus  from  one 
woman  and  deposit  it  in  another,  with  whom  he  cohabits  at  a  short 
interval.  Then  washing  himself,  he  may  escape  infection,  after  having 
none  the  less  occasioned  chancroid  in  the  last-mentioned  woman.  The 
same  intermediate  part  may  be  played  by  the  sound  vagina — a  woman 
receiving  the  poison  from  one  man,  transferring  it  shortly  to  another 
in  sexual  intercourse,  and  herself  escaping.  This  is  mediate  contagion. 
Cullerier's  *  two  famous  experiments  on  women  establish  beyond  dis- 
pute the  fact  that  chancroidal  pus  may  lie  for  some  length  of  time  in 
contact  with  a  vagina,  presenting  no  abrasions,  without  being  absorbed. 
In  these  experiments  chancroidal  pus  from  the  groin  was  deposited  in 
the  vagina,  the  latter  showing  no  abrasions,  and  its  secretions  being 
inoculated  with  negative  result.  In  one  case  the  pus  was  left  in  the 
vagina 'thirty-five  minutes,  in  the  other  nearly  an  hour  ;  the  patients, 
ignorant  that  they  were  the  subject  of  experiment,  were  made  to  walk 
about,  closely  watched.  Finally,  some  of  the  vaginal  secretion  was 
again  collected,  and  successfully  auto-inoculated  in  both  cases.  The 
vagina  was  thoroughly  washed  out  with  an  astringent  solution,  and 
did  not  become  ulcerated  in  either  case,  although  the  poisonous  pus 
had  remained  for  some  time  in  contact  with  its  walls. 

These  two  cases  at  once  raise  the  question,  Can  chancroidal  pus  be 

*  "  Quelques  Points  dc  la  Contagion  mediate,"  Mem.  de  la  Sec.  de  Chir. 
30 


466  CHANCROID. 

absorbed  except  through  an  abrasion  ?  Evidently  not  at  once,  as  the 
two  cases  prove,  nor  probably  in  any  length  of  time  through  the  hard 
epithelium  of  the  skin,  for  hospital  patients,  little  careful  as  to  clean- 
liuess,  handle  with  impunity  their  chancroids  from  day  to  day,  and 
do  not  inoculate  their  lingers,  except  through  ])re-existing  abrasions  ; 
but  that  the  poison  may  enter  through  a  mucous  surface  not  visibly 
abraded  is  certain,  whether  by  direct  absorption,  or  by  corroding  for 
itself  a  way,  has  not  as  yet  been  demonstrated  ;  but  in  all  i)roba- 
biiity  by  the  latter  means.  In  this  way  may  be  explained  chancroid 
with  a  comparatively  long  period  of  incubation.  A  man  lies  with  a 
woman  having  chancroid.  lie  inspects  himself  after  the  act  and  finds 
no  abrasion,  but,  neglecting  to  wash  himself,  pulls  forward  the  pre- 
puce and  goes  on  his  way.  A  small  quantity  of  virulent  ])us  remains 
in  the  little  pocket  alongside  of  the  frajnum,  Avhere  the  mucous  mem- 
brane is  very  thin  and  always  moist.  The  pus,  by  its  acridity,  destroys 
the  superficial  layers  of  epithelium  in  a  few  days,  and  then,  finding  a 
loop-hole  for  absorption,  poisons  the  spot  at  once,  and  the  patient 
appears,  perhaps  a  week  after  his  suspicious  intercourse,  with  a  chan- 
croid only  just  commencing,  the  long  period  of  incubation  here  being 
more  apparent  than  real.  In  like  manner  a  few  pus-corpuscles  rubbed 
into  the  mouth  of  a  minute  follicle  during  the  friction  which  accom- 
panied the  sexual  act  could  not  be  washed  away,  and  by  the  same  pro- 
cess of  corrosion  give  rise  to  a  characteristic  ulcer,  after  a  period  of 
apparent  but  not  real  incubation  (follicular  chancroid). 

Situation  of  Chaxcroid. — Chancroid  is  rarely  found  far  from 
the  genitals,  for  the  obvious  reason  that  it  is  usually  too  consjiicuous 
to  be  lightly  handled,  except  by  the  accoucheur  or  the  surgeon  who 
has  it  under  treatment.  It  was  at  one  time  supposed  that  chancroid 
could  not  occur  upon  the  head  or  face,  but  now  medical  literature  con- 
tains several  cases  of  undoubted  chancroid  of  the  face,  giving  positive 
result  by  auto-inoculation,  and  not  followed  by  syphilis  (Bassereau, 
Boeck,  Puche,  Eofeta,  and  others) ;  while  syi^hilizers  have  abundantly 
proved  that  the  head  and  face,  as  well  as  any  other  portion  of  the 
tegumentary  exi^ansion,  may  be  successfully  inoculated  wath  chan- 
croid. Boeck,  however,  in  studying  the  susceptibility  of  the  different 
portions  of  the  body  to  the  action  of  chancroid  poison,  found  that  in- 
oculation produced  upon  the  cheeks  or  head  only  small,  shallow  ulcera- 
tions of  comparatively  short  duration ;  *  the  chest  and  abdomen  come 
next,  then  the  arms,  and,  finally,  the  thighs,  which  would  furnish 
positive  results  to  inoculation  after  the  latter  had  become  impossible 
upon  the  upper  portions  of  the  body. 

Chancroids  upon  the  male  genitals  appear  by  preference  in  the 

*  But  that  chancroid  may  be  occasionally  severe  on  the  head  is  proved  by  a  case  re- 
ported by  R.  W.  Taylor,  in  Brown-S^quard's  "Archives,"  No.  5,  1873,  and  three  by  Pro- 
feta,  "Ann.  de  Derm,  ct  de  Syph  ,"  1873-74,  No.  3. 


SYMPTOMS.  4fj7 

sulcus  on  either  side  of  the  fraenum,  but  may  occupy  any  position 
even  to  the  inside  of  the  urethra,  where  they  are  occasionally  found, 
usually  occupying  the  meatus,  and  thence  extending  inward,  or  wholly 
concealed  inside  the  canal.  Duncan  inoculated  his  own  urethra  by 
transporting  into  it  some  chancroidal  pus.  He  got  urethral  chan- 
croid with  double  bubo.*  liicord  figures  a  case  of  deep  urethral  chan- 
croid, with  chancroidal-looking  ulcerations  of  the  bladder,  but  tuber- 
cular ulceration  has  been  suggested  to  explain  this  unusual  case. 
Intra-uterine  chancroids  in  the  female  have  been  reported  (Delmas 
and  Combal).  Scrotal  chancroids  mainly  result  from  auto-inocula- 
tion of  abrasions  by  discharges  from  some  chancroid  of  the  penis  or 
under  the  prepuce.  Chancroid  of  the  anus  is  rare  in  the  male.  In 
the  female,  where  the  poisonous  discharges  trickle  from  the  posterior 
vaginal  fourchette  over  the  anus  whenever  the  patient  lies  upon  the 
back,  they  are  not  uncommon.  In  the  male,  when  not  resulting  from 
pederasty,  they  are  rare.  That  chancroid  may  develop  upon  patho- 
logical as  well  as  normal  tissues  is  proved  by  the  successful  inoculation 
by  Boeck  and  others  upon  elephantiasis,  and  by  a  case  reported  by 
Breslau  f  of  chancroid  found  upon  an  epithelial  cancer  of  the  uterine 
neck  giving  positive  results  by  inoculation. 

Symptoms. — The  symptoms  of  chancroid  may  be  best  observed  by 
studying  the  course  of  the  artificial  ulcer  produced  by  inoculation. 
The  smaller  the  inoculation  the  more  perfect  the  result.  It  has  been 
noticed  in  the  large  chancroids  produced  by  inoculation  of  scarified 
surfaces  that  the  lesion  often  develops  from  many  initial  centers, 
numerous  points  on  the  scarified  surface  "  taking,"  the  whole  consti- 
tuting a  multiple  chancroid,  which  soon  unites  into  one.  To  inocu- 
late properly,  a  lancet  or  pin  should  be  used  ;  the  latter  can  always  be 
obtained  new,  clean,  and  sharp.  If  a  lancet  be  employed  in  any  doubt- 
ful case  to  inoculate  as  a  test,  it  should  always  be  scrupulously  cleaned 
before  use.  With  the  lancet,  Boeck's  method  is  the  best.  Scrape  a 
little  pus  on  the  point  of  the  instrument,  hold  the  point  at  right 
angles  to  the  surface  of  the  skin,  and  cause  it  to  penetrate  just  barely 
below  the  epidermis ;  then  rotate  the  instrument,  held  in  the  same 
direction,  half  round  and  back  ;  withdraw  it,  and  smear  over  the  little 
red  point  with  whatever  pus  remains  upon  the  end  of  the  lancet. 
Within  twenty-four  hours  after  such  an  inoculation,  a  reddish  blush 
will  envelop  the  puncture  ;  on  the  second  day  the  little  dark  speck  of 
dried  blood  is  surrounded  by  a  faint,  inflamed  areola.  Occasionally 
there  is  already  commencing  pustulation  on  the  second  day,  usually 
on  the  third  day,  sometimes  later.  The  red  areola  enlarges,  and  sur- 
rounds a  vesico-pustule.  Break  this,  and  beneath  will  invariably  be 
found  an  ulcer,  a  perfect,  fully-formed  chancroid  in  miniature.     If 

*  "Cours  des  Maladies  syphilitiques,"  Petit-Eadel,  1S12. 
f  "  Archiv  der  Heilkunde,"  1861. 


4G8  CHANCROID. 

left  alone,  the  vesico-pustule  beeomcs  an  ecthymatous  jnistule,  which 
usually  breaks  in  a  few  Jays  after  it  has  reached  the  size  of  a  s})lit  pea. 
The  circular  ulcer  which  results,  continuing  circular,  enlarges  and 
deepens.  It  usually  becomes  stationary  before  it  reaches  the  size  of  a 
half-dime,  but  mtiy  become  as  large  as  a  silver  quarter  of  a  dollar,  or 
occasionally  far  exceed  it.  This  ulcer  is  a  true  chancroid,  resembling 
in  every  minute  particular  the  ulcer  from  which  it  si)rung  by  inocula- 
tion, and  tending  to  run  a  similar  course. 

It  is  evident,  from  the  foregoing  descrii)tion,  that  chancroid  has  no 
])eriod  of  incubation  or  hatching.  When  the  virus  is  placed  in  a 
l)osition  where  absorption  is  possible,  it  commences  its  work  at  once, 
and  ra))idly  reaches  the  stage  of  ulceration.  In  the  same  way  the 
chancroid  acquired  in  sexual  intercourse  has  no  period  of  incubation, 
this  point  being  perhaps  of  all  the  most  important,  as  distinguishing 
it  from  syphilitic  chancre.  Usually  by  the  third  day  after  suspicious 
intercourse,  occasionally  as  late  as  a  week,  or  rarely  later,  where  the 
jius  has  had  to  employ  several  days  to  corrode  the  ei)ithelium  before 
gaining  excess  to  the  vascular  tissue  beneath,*  a  small  ulcer  will  bo 
found,  which  has  the  characters  of  a  chancroid,  characters  which 
apply  to  a  chancroid  ulceration  of  whatever  size,  wherever  situated, 
originating  from  natural  contagion  or  from  inoculation.  These  char- 
acters are  :  a  rounded,  sometimes  oval  margin,  abrupt,  perpendicular 
edges,  looking  as  if  they  had  been  cut  out  by  a  sharp-edged  punch, 
sometimes  everted.  The  ulceration  is  rather  deep  considering  its 
extent ;  in  very  rare  instances,  shallow,  like  herpes  ;  the  bottom  is 
irregular,  velvety,  grayish-yellow,  covered  by  a  pultaceous,  adherent 
substance  resembling  false  membrane  or  wet  wash-leather,  composed 
of  partlv-destroyed  elements  of  the  skin  and  pus,  with  perhaps  some 
irregular,  pale  granulations.  The  whole  is  usually  bordered  by  a  pink 
areola.  Under  favorable  circumstances  there  is  no  surrounding  in- 
flammation, there  is  no  hardness  under  or  around  the  ulcer,  which 
rests  on  a  perfectly  soft  base.  The  suppuration  is  abundant,  rather 
thick  and  creamy,  mixed  with  organic  detritus,  not  generally  tinged 
with  blood.  There  is  little  or  no  pain.  Such  a  description  applies 
to  a  type  case  which  has  never  been  irritated  mechanically  or  chemic- 
ally. This  single  ulcer  runs  through  its  stages  of  increase,  stationary 
period,  and  repair,  provided  it  is  allowed  rest  and  is  not  irritated,  and 
pursues  a  natural  course,  as  follows  : 

CouESE  OF  Chancroid. — It  increases  in  size  for  one  or  two  weeks, 
preserving  its  characteristics,  and  reaching  a  variable  size,  often  not 
larger  in  diameter  than  a  quarter  of  an  inch.     Of  this  size  it  remains 

*  Foumior,  in  a  carefully  observed  statistic  of  fifty-two  cases,  where  the  patient  would 
acknowledge  but  one  sexual  contact  for  the  previous  four  or  five  months,  found  twenty- 
four  developed  within  the  first  four  days,  forty-one  within  eight  days,  others  later,  the 
sore  being  often  quite  large  when  discovered. 


VARIATIONS   FROM   NATURAL   TYPE.  4,09 

for  a  period  of  perhaps  two  weeks,  undergoing  no  appreciable  change  ; 
or  there  may  be  no  stationary  period,  repair  setting  in  at  once  after 
the  ulcer  has  reached  a  certain  size.  Finally,  repair  is  announced  by 
a  more  creamy,  laudable  condition  of  the  pus,  a  sloping  of  the  abrupt 
edges,  and  a  clearing  up  of  the  cavity  of  the  ulcer,  which  becomes 
rosy,  granular,  and  gradually  cicatrizes  from  the  edges  toward  the 
center.  During  the  whole  period  of  its  existence  the  chancroid  fur- 
nishes auto-inoculable  pus.  The  old  theory,  that  after  repair  was  well 
advanced  the  secretion  ceased  to  be  poisonous,  is  no  longer  tenable. 
Truly,  the  degree  of  virulence  is  lessened  with  advancing  repair,  but 
Fournier  has  recently  been  able  to  obtain  occasional  positive  results 
by  auto-inoculation  from  chancroids  which  were  nearly  cicatrized. 

This  important  fact,  that  the  secretions  of  chancroid  are  conta- 
gious until  the  cicatrix  is  formed,  has  but  two  exceptions  :  1.  When 
gangrene  attacks  a  chancroid,  its  discharges  are  not  contagious,  nor 
does  the  granular  surface  left  by  the  separation  of  the  slough  any 
longer  afford  a  poisonous  secretion.  2.  Certain  very  old  chancroids, 
usually  such  as  have  been  of  considerable  size  and  are  situated  in  posi- 
tions where  they  are  kept  irritated  and  prevented  from  healing,  per- 
haps for  years,  sometimes  lose  their  poisonous  properties  finally,  and 
become  simple  chronic  ulcers,  kept  open  by  contact  of  irritating  dis- 
charges, muscular  contractions,  and  motion  of  the  parts  on  which 
they  are  situated.  Such  ulcers  are  found  in  the  anus  and  rectum  of 
the  male,  and  in  the  vaginae  of  old  prostitutes. 

The  SCAR  left  by  chancroid  varies  with  the  depth  of  the  ulcer.  It 
may  be  so  faint  as  shortly  to  disappear,  leaving  no  trace  ;  or,  again, 
may  remain  indelible,  as  a  seamed  and  puckered,  unsightly  scar,  of  a 
size  proportioned  to  the  previous  ulceration. 

But  this  mild  and  simple  sequence  of  events  in  chancroid  is  far  from 
being  constant.  All  sorts  of  variations  from  the  natural  type  occur  : 
in  («)  initial  form,  (b)  shape,  (c)  number,  [d]  size,  (e)  duration,  (/) 
pain,  {g)  condition  of  base,  (h)  relapse,  and  finally  the  complications 
of :  (i)  vegetations,  (_/)  syphilitic  chancre,  (k)  inflammation,  (I)  gan- 
grene and  gangrenous  phagedena,  (?»)  phagedena,  {}i)  bubo,  (o)  lym- 
phitis. 

(a)  Varieties  in". Initial  Form. — Usually  chancroid  of  a  mucous 
membrane  presents  itself  from  the  first  as  an  ulcer,  but  occasionally  the 
initial  pustule  may  be  seen.  This  breaks,  disclosing  the  characteristic 
ulcer,  or,  occasionally  on  the  skin,  does  not  break,  but  dries  into  a 
scab.  The  scab  increases  in  size  by  additions  of  pus  from  beneath,  and 
covers  the  ulcer  ;  but  the  pus,  which  may  be  squeezed  from  the  sides 
by  pressure  upon  the  loosely-attached  crust,  is  auto-inoculable,  and  if 
the  crust  be  removed  true  chancroid  is  disclosed.  The  French  call  this 
form  "ecthymatous  chancroid."  Again,  the  chancroid  pustule  may 
originate  in  the  orifice  of  a  sebaceous  gland  of  the  scrotum  or  penis. 


470  CHANCROID. 

and  be  mistaken  readily  at  first  for  simple  acne,  or  the  lesion  may  re- 
semble a  small  boil  at  its  commencement  (follicular  chancroid).  The 
primary  lesion  may  be  a  papule  surmounted  by  a  inistnle,  or,  still  more 
rarely,  a  bulla  (Fournier).     These  latter  forms  are  exceptionally  rare. 

{h)  Varieties  in  Shape. — The  usual  round  or  oval  form  of  chan- 
croid is  subject  to  exception.  If  a  wound  be  inoculated,  the  chancroid 
takes  the  form  of  the  wound.  So  of  a  fissure,  as  is  often  beautifully 
seen  in  chancroid  of  the  anus,  such  a  chancroid  being  frerpiently  mul- 
tiple, standing  off  in  rays  from  the  puckered  center,  or  extending  up 
irregularly  into  the  gut,  perhaps  for  several  inches.  Two  neighboring 
chancroids  may  coalesce,  producing  one  sore  of  irregular  shape,  with 
borders  composed  of  segments  of  circles.  The  ulcer  may  undermine 
the  fra^num,  or  follow  around  the  sulcus  behind  the  corona  glandis. 
It  may  cicatrize  on  one  side  and  advance  on  the  other,  or  finally 
assume  any  variety  of  shape  from  the  modifying  influence  of  gangrene 
or  phagedena. 

((')  Varieties  in  Nl'mber. — Chancroid  may  be  unique,  or  any 
given  number  may  coexist.  Sperino,  in  practicing  syphilization,  was 
in  the  habit  sometimes  of  inoculating  in  eiglity  places  at  once,  since  he 
found  that,  by  so  doing,  the  size  of  the  resulting  ulcers  was  smaller. 
Chancroid  is  often  multiple  fi'om  the  first,  when  several  abrasions  arc 
simultaneously  inoculated  during  the  sexual  act ;  or,  starting  unique, 
may  become  multiple  to  any  extent  by  auto-inoculation,  especially  in- 
side the  prepuce  ;  anal  chancroid  is  usually  multii^le.  It  is  not  uncom- 
mon with  a  tight  prepuce  to  find  half  a  dozen  small  chancroids  situated 
just  on  the  preputial  margin,  or  the  whole  rim  may  be  one  ulceration. 
Usuallv,  when  chancroid  is  multiple  from  the  beginning,  each  ulcer 
is  small. 

{(I)  Varieties  in  Size. — The  size  varies  from  that  of  the  head  of 
a  pin  to  enormous  phagedenic  surfaces,  covering  half  the  belly. 

(e)  Varieties  in  Duration. — A  chancroid  untreated  never  lasts 
less  than  a  month.  The  larger  the  size  the  slower  the  repair,  other 
things  being  equal.  Gangrenous  sores  may  continue  for  months,  and 
phagedenic  serpiginous  chancroids,  as  a  rule,  for  many  months,  excep- 
tionally for  a  number  of  years.  Chancroids  of  the  meatus  urinarius, 
constantly  irritated  by  urine,  are  very  slow  in  getting  well.  Certain 
old  chancroids  of  the  rectum,  which  have  partly  cicatrized,  forming 
stricture,  may  be  kept  open  by  local  irritation,  and  perhaps  never  get 
well,  although  their  secretions  finally  cease  to  be  inoculable.  The 
same  may  be  said  of  certain  old  chantroids  in  the  female  vagina,  which 
erode  large  portions  of  the  walls  of  the. canal  and  the  labia,  perhaps 
at  the  same  time  extending  over  the  perinaeum,  and  including  the 
anus  and  rectum.  These  also  finally  cease  to  progress,  but  remain 
open  for  years,  as  simple  chronic  ulcers,  not  auto-inoculable,  perhaps 
surrounded  by  hardened  cicatricial  tissue,  attended  by  little  or  no  pain 


VARIATIONS  FROM  NATURAL  TYPE.  471 

or  inflammation  ;  perhaps  resting  on  a  hard  base,  looking  pultaceous 
or  sometimes  dry  and  red  without  granulations.  These  ulcers  are 
kept  from  healing  by  the  condition  of  the  patients,  mostly  middle- 
aged  prostitutes,  broken-down  hospital  cases,  often  suffering  from 
syphilis  at  the  same  time,  and  by  the  contact  of  urine  and  the  move- 
ments of  the  parts  ;  the  hard,  unhealthy  base  of  the  nicer  proves  also 
a  decided  obstacle  to  healthy  action  in  the  sore.  This  variety  of  ulcer 
has  been  best  described  by  Boys  de  Loury  et  Costilhes.*  These  ulcera- 
tions in  the  female  vagina  are  often  mistaken  for  tertiary  syphilitic 
serpiginous  ulcers,  especially  if  the  patient  have  syphilis  at  the  same 
time.  The  distinction  is  often  difficult,  even  impossible,  except  by 
studying  the  history  of  the  ulcer.  Syphilitic  ulcer  will  be  found  to 
have  commenced  as  a  tubercle,  having  no  connection  in  point  of  time 
with  sexual  intercourse,  and  there  will  often  be  some  tuberculization 
of  the  edges  of  the  sore.  Tubercular  syphilitic  ulceration,  once  started, 
may  become  phagedenic,  just  as  well  as  chancroid  ;  and  the  contact 
of  urine,  the  habits  of  the  patient,  motion,  the  callous  condition  of 
the  base  of  the  sore,  etc. ,  may  prevent  anti-syphilitic  remedies  from 
exerting  such  a  marked  beneficial  influence  as  might  have  been  ex- 
pected, so  that  diagnosis  becomes  exceedingly  difficult.  Should  some 
of  the  poisonous  secretions,  however,  still  remain  upon  the  ulcers, 
auto-inoculation,  if  it  takes,  will  at  once  remove  all  doubt,  and  this 
test  may  be  employed.  A  negative  result,  however,  does  not  prove 
that  the  lesion  was  not  a  chancroid  at  its  commencement,  and  the 
probability  is  always  in  favor  of  such  a  supposition.  Phagedena  alone 
does  not  destroy  the  inoculability  of  the  discharge.  Some  authors 
describa  these  ulcers  as  a  variety  of  lupus.  Extensive  scraping  and 
cauterization  will  sometimes  cure  them. 

(/)  Varieties  in-  Pain". — Chancroid  may  be  almost  entirely 
painless,  only  attended  by  some  itchy,  prickling  sensations.  Any  irri- 
tation applied  to  it,  however,  occasions  pain  at  once,  so  that  clinically, 
instead  of  being  absent,  pain  is  usually  a  diagnostic  symptom  of  chan- 
croid, serving  to  distinguish  it  from  syphilitic  chancre.  All  sorts  of 
irritating  and  many  simple  stimulating  dressings  are  liable  to  cause 
pain,  sometimes  even  cold  water  (Fournier).  The  position  of  the  sore 
on  the  end  of  the  penis,  which  usually  hangs  down,  erections;  which 
pull  upon  its  edges,  contact  of  urine,  retention  of  pus  on  the  surface, 
all  these  causes  serve  to  inflame  a  chancroid  and  give  rise  to  pain.  In 
two  pathological  conditions  pain  is  often  very  severe  in  chancroid — 
when  it  is  attacked  by  gangrene  or  by  phagedena,  and  when  it  is  ad- 
vancing rapidly. 

(g)  Condition"  of  the  Base  (Ijstduratiox). — The  chancroid 
when  not  irritated  reposes  upon  a  perfectly  soft  base.     When  irritated 

*  "  Des  Ulcerations  chroniques,  ou  Chancres  chroniques  des  Parties  genitales  de  la 
Femme,".  Paris,  1845. 


472  cnANTROin. 

or  inflamed,  an  indnmtion  is  caused,  sometimes  slight,  sometimes  ex- 
tensive, recalling  the  hardness  around  a  boil.  This  is  an  accidental 
and  not  a  natural  phenomenon,  and  is  an  important  distinguishing 
mark  between  chancroid  and  syphilitic  chancre.  The  base  of  herpes, 
excoriations,  abrasions,  vegetations — in  short,  of  any  lesion  about  the 
genitals — is  liable  to  indurate  if  irritated  or  inflamed.  Sometimes 
this  induration  resembles  syphilitic  induration  very  closely,  but  usu- 
ally it  is  easily  distinguishable.  It  is  an  inilammatory  hardness,  the 
tissues  are  evidently  glued  and  matted  together,  tlie  edges  of  the  indu- 
ration lose  themselves  gradually  in  the  surrounding  tissues,  and  do 
not  end  abruptly  as  in  syphilitic  induration.  There  is  more  pain  on 
pressure  than  in  the  latter.  The  induration  never  precedes  ulceration 
as  in  syphilitic  chancre,  and,  linally,  the  feel  itself  is  different,  very 
unlike  the  woody,  cartilaginous,  elastic  feel  of  syphilitic  induration. 
Besides  inflammation  from  any  irritating  cause,  contact  of  urine,  fric- 
tion, position  (chancroid  of  the  meatus  urinarius  almost  invariably 
indurates,  as  do  most  often  chancroids  under  a  tight  prepuce  which 
has  become  phimotic  from  inflammation),  many  substanoes  commonly- 
applied  as  dressings  to  chancroid  are  directly  instrumental  in  causing 
hardness  of  the  base  ;  all  caustics,  acid  or  alkaline,  especially  if  aj^- 
plied  sparingly,  and  perhaps  most  particularly  nitrate  of  silver,  solu- 
tion of  corrosive  sublimate,  or  chromate  of  potash  (Fournier).  In 
fact,  there  are  so  many  natural,  accidental,  and  medicinal  causes  for 
induration,  that  it  is  rather  surprising  that  any  chancroids  escape 
them  all  and  remain  soft  to  the  end,  as  many  of  them  certainly  do. 

{h)  Eelapse. — A  chancroid  may  have  fairly  entered  the  period  of 
repair,  or  even  be  far  advanced  in  it,  when  suddenly,  perhaps  from  irri- 
tation, often  without  appreciable  cause,  it  relapses,  resuming  all  the 
characteristics  of  chancroid,  and  advancing  a  second  time  for  a  vari- 
able period.  More  rarely  a  relapse  may  occur  a  second  or  even  a 
third  time. 


COMPLICATIONS    OF    CHANCROID. 

Of  all  the  complications  of  chancroid — inflammation,  vegetations, 
phimosis,  paraphimosis,  lymphangitis,  erysipelas,  gangrene,  phagedena, 
simple  bubo,  and  virulent  bubo — not  one  is  peculiar  to  chancroid  ex- 
cept the  last.  Each  and  all  of  the  others  may  complicate  any  herpetic, 
simple,  inflammatory,  or  even  syphilitic  lesion  of  the  genitcils,  but  nat- 
urally they  are  oftener  found  witli  the  more  virulent  sore — chancroid. 
This  fact  must  be  constantly  borne  in  mind. 

(i)  Vegetatioxs. — These  papillary  growths  may  complicate  chan- 
croid, as  they  may  any  other  lesion  (inflammatory,  syphilitic,  or  gonor- 
rhoeal),  especially  of  the  prepuce  or  around  the  anus  (for  Vegetations, 
see  page  23). 


COMPLICATIONS.  473 

(/)  Syphilitic  Chancre  may  complicate  chancroid  by  appear- 
ing alongside  of  it,  or  on  the  same  spot  as  mixed  chancre  (which  see, 
joage  521). 

{k)  Inflammation,  spontaneous  (from  plethora,  deljility,  drink- 
ing), mechanical  (from  friction,  erection,  position),  chemical  (from 
contact  of  urine,  lack  of  cleanliness,  inappropriate  dressings),  is  a  fre- 
quent complication  of  chancroid.  Especially  is  this  true  when  the 
ulcer  is  sub-prcputial,  if  the  prepuce  be  long  or  congenitally  tight. 
Phimosis  and  paraphimosis  are  often  encountered  with  chancroid, 
lymphangitis  is  yery  liable  to  occur  (with  enormous  oedema  of  the 
prepuce,  perhaps  of  the  whole  penis),  and  possibly  erysipelas,  Avhile 
the  retained  discharges  and  the  tension  of  the  parts  predispose  strongly 
to  sloughing  and  phagedena.  An  inflamed  chancroid  gets  painful  at 
once.  It  indurates  and  may  become  livid,  its  secretion  grows  thinner 
and  more  bloody,  while  its  ulceration  deepens.  Inflamed  chancroid 
is  very  liable  to  be  attended  by  suppurating  bubo.  Abscess  may  form 
in  the  thickness  of  the  prepuce,  and,  opening,  remain  indefinitely 
fistulous.  With  phimosis  pus  may  be  retained  and  burrow  backward, 
sometimes  in  a  narrow  tract  at  the  end  of  which  an  abscess  forms, 
opens,  furnishes  inoculable  pus,  and  remains  fistulous.  This  burrow- 
ing may  sometimes  go  on  to  an  enormous  extent,  Vidal  saw  a  case 
where  the  whole  skin  of  the  penis  was  separated  up  to  the  root  of  the 
scrotum.  The  integument  of  any  portion  of  the  body  may  under- 
mine from  retained  chancroid  pus,  by  a  species  of  subcutaneous 
phagedena.  In  patients  who  are  run  down  constitutionally,  clian- 
croid  sometimes  pursues  a  course  of  slow,  chronic  inflammation.  Such 
an  ulcer  is  painful,  surrounded  by  a  red  areola,  with  perhaps  a  hard 
base  and  undermined  border.  The  base  looks  pultaceous,  discharges 
a  thin,  perhaps  sanious  secretion,  which  often  dries  into  a  scab. 
Chancroids  of  this  description  may  increase  in  size  and  become  phage- 
denic or  remain  stationary  for  a  long  time.  They  are  sometimes  at- 
tended by  paroxysms  of  feverishness,  with  symptoms  of  gastric  dis- 
turbance. 

{I)  GrANGRENE  AND  GANGRENOUS  PHAGEDENA. — Gangrene  is  a 
complication  not  confined  to  chancroid,  as  it  may  be  engrafted  upon 
other  lesions  of  the  penis.  It  is  of  two  kinds  :  total  (self-limiting),  or 
progressive  (phagedenic).  The  first-mentioned  variety  commonly  ac- 
companies a  high  degree  of  inflammation,  as  in  connection  with  inflam- 
matory phimosis  or  paraphimosis,  where  the  tension  of  the  parts  is 
great,  and  they  suddenly  and  in  totality  fall  into  gangrene.  In  this 
way  the  whole  prepuce  may  be  lost,  artificial  circumcision  being  neatly 
performed  by  the  separation  of  the  slough.  The  whole  glaus  penis 
may  slough  away,  or  a  swollen  and  inflamed  prepuce,  retaining  the 
pus  of  the  chancroids  within,  perhaps  suddenly  becomes  blackish  green 
over  a  greater  or  less  area,  a  slough  forms,  separates,  letting  the  head 


474  CHANCROID. 

of  the  i>cnis  tliroiigh,  leaving  behind  a  seemingly  double-headed,  un- 
sightly member,  tlie  remains  of  the  prepuce  below  becoming  hardened, 
OBdematous,  sometimes  greatly  increased  in  size  by  chronic  inflamma- 
tory hypertrophy.  Total  gangrene  rarely  attacks  chancroid,  except 
where  tiie  ulcers  are  sub-preputial. 

Besides  the  immediate  exciting  cause  (great  inflammatory  tension), 
the  predisposing  causes  are  any  debilitating  agencies,  malarial  or  other 
cachexia^  old  age,  alcoholism,  etc.  Total  gangrene  of  the  whole  chan- 
croidal surface  at  once  destroys  it  just  as  certainly  as  does  the  thorough 
application  of  an  eflicient  caustic.  In  both  cases  alike  neither  the 
slough  nor  the  pus  formed  beneath  it  in  the  natural  process  of  its 
elimination  possesses  any  poisonous,  inoculable  properties.  After  the 
slough  has  fallen,  a  healthy,  granulating,  non-virulent  ulcer  is  left, 
which  usually  goes  on  at  once  to  repair,  with  rapidity  proportionate 
to  the  vitality  of  the  individual.  But  just  as  an  imperfect  applica- 
tion of  caustic  to  a  chancroid  only  produces  a  partial  slough,  and  does 
not  do  away  with  the  poisonous  properties  of  the  sore,  since  the  virus 
is  secreted  by  all  portions  alike,  and  if  any  is  left  the  whole  is  repoi- 
soned,  so  there  may  be  spontaneously  progressive  gangi-ene  of  the 
phagedenic  sort,  attacking  a  chancroid  not  thoroughly  destroying  the 
secreting  surface,  and  consequently  not  interfering  with  the  inocula- 
ble properties  of  the  pus.  Under  these  circumstances  a  black  slough 
forms  on  the  surface  of  the  sore,  but  it  does  not  separate  ;  pain  con- 
tinues, and  a  new  slough,  forms  or  the  old  one  progresses  ;  and  so  on, 
in  a  phagedenic  manner,  sometimes  slowly,  sometimes  rapidly,  often 
large  portions  of  skin  and  underlying  tissue  being  destroyed  before  the 
sloughs  finally  separate,  and  leave  healthy  surfaces  beneath.  This 
variety  of  gangrene  constitutes  one  (the  less  common)  form  of  phage- 
dena, and  is  responsible  for  many  of  the  extensive  mutilations  accom- 
panying chancroid.  "With  forming  or  advancing  gangrene  there  is 
intense  pain,  and  always  some  general  constitutional  disturbance, 
fever,  etc.,  which  does  not  obtain  in  true  phagedena.* 

The  physical  signs  of  gangrene,  when  attacking  a  chancroid  which 
is  visible,  are  similar  to  what  is  observed  in  gangrene  elsewhere.  The 
ulcer  first  begins  to  look  grayish,  the  patient  suffering  great  pain  ;  then 
it  becomes  violet,  finally  greenish  black,  wdiile  the  discharge  grows 
thin  and  fetid.  A  line  of  demarkation  finally  forms,  surrounded  by 
an  inflammatory  areola,  and  if  the  slough  includes  the  entire  ulcer, 
its  separation  leaves  a  healthy  granulating  surface  behind. 

(m)  PnAGEDEXA  is  molecular  gangrene.  But  molecular  gangrene 
is  not  able  to  destroy  the  poisonous  surface  rapidly  enough  to  make  the 
ulcer  a  healthy  one  ;  hence  phagedena,  as  applied  to  chancroid,  signi- 
fies large  extension  of  the  ulcer  with  preservation  of  its  specific  (inocu- 
lable) properties.     Phagedena,  most  commonly  found  with  chancroid, 

*  Cases  of  this  sort  are  not  uncommon  in  hospitals. 


COMPLICATIONS.  475 

is  not  confined  to  tliis  yariety  of  sore.  SypliilitJc  chancre  is  some- 
times phagedenic  (Rollet  thinks  only  in  tlic  gangrenous  form) ;  dif- 
ferent ulcerated  syphilidos  and  scrofulides  occasionally  become  phage- 
denic. 

Phagedena  advances  superficially,. or  in  depth,  or  both  at  once.  It 
is  pultaceous  in  type,  or,  more  rarely — as  detailed  above — gangrenous. 
The  latter  form,  often  largely  destructive,  is  comparatively  rapid  ;  the 
common  form  (pultaceous,  superficial,  serpiginous,  ambulant)  is  ex- 
ceedingly slow.  Phagedena  advancing  on  one  side  often  gets  well  with 
proportionate  rapidity  on  the  other. 

Clerc  has  established  that  a  chancroid  never  commences  phagedenic, 
but  always  becomes  so  secondarily,  after  having  existed  for  a  while 
uncomplicated.  Chancroidal  phagedena  seems  often  to  be  an'ested  by 
coming  into  contact  with  tissue  of  a  different  order  from  the  one  it  is 
attacking.  It  shows  a  predilection  for  cellular,  connective  tissue,  as 
in  undermining  the  skin  of  the  penis.  Belhomme  *  gives  a  striking 
instance  of  a  phagedenic  serpiginous  chancroid  of  the  skin  stopping 
suddenly  on  reaching  the  mucous  membrane.  This  can  not,  however, 
be  always  counted  on,  but  the  tendency  exists,  as  is  well  shown  by 
the  fact  that  vessels,  nerves,  and  glands  are  often  dissected  out  and 
spared  by  the  advancing  ulceration.  The  corpus  spongiosum,  corpora 
cavernosa,  and  testicles  may  be  bared  by  phagedena,  but  themselves 
remain  untouched.  Fascial  expansions,  and  fibrous  tissue  generally, 
may  be  expected  to  oppose  the  destructive  march  of  phagedena ;  but 
sometimes  nothing  is  spared,  all  the  tissues  being  eaten  through 
indifferently,  by  the  variety  of  phagedena  which  destroys  in  depth 
(mainly  by  slough). 

Phagedena  attacks  virulent  bubo  perhaps  as  often  as  it  does  chan- 
croid.    It  seems,  however,  to  spare  all  except  virulent  buboes. 

The  serpiginous  {serpere,  to  creep)  phagedena  (unlike  the  gangre- 
nous form)  is  attended  by  not  very  great  pain,  and  no  constitutional 
disturbance  ;  there  may  be  slight  headache,  malaise,  etc.  As  it  com- 
mences, the  surrounding  skin  reddens,  the  borders  of  the  ulcer  swell 
and  undermine.  The  true  characters  of  chancroid  are  retained  by  the 
sore  throughout,  the  base  is  uneven  and  (sometimes  with  exuberant 
granulations)  covered  by  the  same  grayish,  adherent,  false-membra- 
nous-looking material,  whence  the  name  jDultaceous  chancroid.  The 
edges  are  sharply  cut,  gnawed,  uneven,  abrupt.  The  discharge  is  thin, 
sanious,  and  inoculable  to  the  end.  The  edges  are  often  undermined, 
thin,  purplish,  perhaps  oedematus.  Pain  of  a  burning  character  at 
the  edges  indicates  advance  of  the  process. 

This  form  of  phagedena  lays  bare  the  penis,  sometimes  the  testi- 
cles, and  may  travel  up  over  the  abdomen,  and  to  any  extent  farther. 
Usually,  however,  the  largest,  most  persistent  chancroids  originate  in 

*  "  Du  Chancre  phagedenique  et  de  son  Traitenient,"  These  da  Paris,  1862. 


47G  CEAXCROID. 

bubo  (which  sec),  bat  the  characteristics  of  the  ulcer  arc  the  same, 
whatcA'cr  its  origin.  No  detinitc  daratit)n  can  be  assigned  to  phage- 
dena. Tlie  chronic  sei^piginous  form,  untreated,  always  lasts  many 
months,  sometimes  many  years.  The  longest  case  recorded  (Fouruier), 
commencing  in  the  groin  in  a  virulent  bubo,  was  still  present  as  an 
open  nicer  of  the  knee  after  fourteen  years,  having  healed  up  behind 
as  it  advanced,  and  this,  indeed,  was  not  untreated,  but  had  been 
under  Ricord's  care  for  several  years. 

The  course  of  phagedena,  like  tliat  of  chancroid,  may  be  continued 
by  successive  relapses.  Perhaps  after  cicatrization  is  nearly  complete, 
phagedena  recommences  without  evident  cause,  and  the  whole  cicatrix 
reopens. 

The  causes  of  phagedena  are  (1)  general  and  (2)  local. 

1.  General. — Whatever  depresses  the  vital  force— bad  hygiene,  in- 
temperance, misery,  digestive  troubles  (Ricord),  scrofula,  lymphatism, 
scorbutus,  malaria.  Chronic  alcoholism  and  old  age  are  prominent 
as  general  causes. 

2.  Local. — Lack  of  cleanliness,  phimosis  from  retention  of  pus, 
fatty  substances  as  dressings,  particularly  mercurial  ointment,  which 
Ricord  considers  a  very  active  cause,  all  sorts  of  local  irritation,  fric- 
tion, etc.  Sperino,*  Salneuve,f  Rollet,  and  others,  have  inoculated 
from  phagedenic  chancroid,  pro4ucing  only  simple  chancroid  ;  and 
Sperino,  with  other  syphilizers,  has  shown  that  the  same  pus  inocu- 
lated on  different  individuals  produced  in  some  simple,  in  others 
phagedenic  sores,  while  confrontation — that  is,  examining  the  woman 
from  whom  the  man  received  his  sore,  or  vice  versa — has  frequently 
revealed  a  phagedenic  sore  derived  from  a  simple  one.  Hence  the 
conclusion  :  There  is  no  special  phagedenic  virus.  Phagedena  is  not 
a  property  belonging  to  chancroidal  pus,  it  is  rather  a  property  of 
the  tissues  of  the  patient — an  individual  idiosyncrasy.  This  fact  is 
substantiated  by  daily  experience,  for  hetero-inoculations  %  with  pha- 
gedenic pus  have  rarely  produced  more  than  a  simple  sore,  while 
auto-inoculation  of  the  same  pus  is  not  unlikely  to  be  attended  by 
phagedena.  Again,  certain  individuals  are  recorded  as  having  had 
chancroids  on  two  different  occasions,  both  times  phagedenic*  In 
some  instances,  however,  we  find  ourselves  unable  to  detect  any  cause 
of  phagedena,  which  may  attack  patients  apparently  in  the  most  robust 
health,  where  none  of  the  general  or  local  causes  mentioned  above  seem 
to  have  been  at  work.  Treatment  will  be  considered  under  treatment 
of  chancroid. 

*  "  Studi  clinici  sul  Virus  sifilitico,"  Turin,  18G3. 

+  "De  laValeur  semeioiogiquc  dcs  Affections  ganglionnaircs,"  These  de  Paris,  1852. 
\  Inoculations  upon  one  individual  from  another. 

*  Xegroes  suffer  more  than  whites  from  phagedena,  as  indeed  tliey  do  from  chancroid, 
bubo,  syphilis,  or  even  gonorrhoea  as  a  rule. 


DIAGNOSIS.  ^  477 

(n)  Bubo  and  (o)  lymphangitis  will  bo  described  after  the  section 
on  treatment. 

Diagnosis  of  Chancroid. — The  diagnosis  of  chancroid  is  with 
herpes,  balanitis  with  excoriations,  exulcerated  abrasions,  syphilitic 
chancre,  simple  ecthyma,  ulcerated  mucous  patch,  ulcerated  (tertiary) 
tubercular  syphilide  of  the  glans  penis  or  prepuce,  epithelioma.  The 
distinguishing  peculiarities  of  the  four  most  common  of  these  lesions 
— syphilitic  chancre,  chancroid,  herpes,*  ulcerated  abrasion — will  be 
described  and  considered  side  by  side  in  the  diagnostic  table  following 
syphilitic  chancre.  Of  the  others,  the  ulcerated  mucous  patch  rarely 
presents  the  same  depth  of  ulceration,  or  tendency  to  spread,  and  mu- 
cous patch  furthermore  is  apt  to  coexist  with  other  similar  lesions  of 
the  mouth  or  anus.  Dischai'ge  from  mucous  patches  is  in  a  measure 
auto-inoculable,  but  does  not  of  course  produce  typical  chancroid. 
Finally,  tertiary  syphilitic  ulcerations  of  the  glans  or  prepuce  often 
resemble  chancroid  so  accurately  that  no  physical  characteristic  is 
wanting.  Usually,  however,  the  edges  are  harder,  as  is  the  base,  the 
ulceration  more  irregular  in  outline,  the  tendency  to  eat  deeply  more 
marked,  the  pain  and  inflammation  less.  The  discharge  is  not  auto- 
inoculable.  With  any  one  of  these  lesions  there  may  be  local  inflam- 
mation and  consequent  suppurating  bubo,  or  even  lymphangitis,  but,  in 
any  case,  if  a  bubo  suppurate  and  its  pus  be  found  auto-inoculable,  it 
has  derived  its  origin  with  absolute  certainty  from  a  chancroid,  and 
from  a  chancroid  only.  In  any  case  of  doubt,  in  presence  of  a  suspi- 
cious sore,  there  remains  one  infallible  method  of  diagnosis  ;  namely, 
auto-inoculation. 

Auto-inoculation  is  most  safely  practiced  in  one  of  three  situations  : 
under  the  nipple,  where  Boeck  has  shown  that  chancroid  naturally  runs 
a  mild  course,  over  the  insertion  of  the  deltoid,  or  on  the  outer  part  of 
the  thigh.  In  all  of  these  localities  the  artificially-produced  sore  is  not 
liable  to  be  complicated  by  bubo,  on  account  of  the  distance  of  the 
lymphatic  glands,  nor  is  it  likely  to  accidentally  inoculate  surrounding 
parts.  Of  course  after  an  inoculation  has  fairly  taken,  and  served  its 
end  as  a  crucial  diagnostic  test,  it  should  be  promptly  destroyed  by  a 
drop  of  acid.  In  certain  cases  it  is  absolutely  impossible  to  arrive  at  a 
diagnosis  without  consulting  this  test,  as  where  the  chancroid  can  not 
be  seen — sub-preputial  chancroid  with  phimosis,  intra-urethral  chan- 
croid, anal  chancroid  resembling  fissure.  In  intra-urethral  chancroid, 
the  auto-inoculability  of  the  pus  is  sometimes  the  only  diagnostic 
symptom  ;  in  other  cases  there  is  a  painful  spot  in  the  urethra  during 
erection,  and  a  lump  that  may  be  felt  from  the  outside  ;  possibly  viru- 
lent bubo  accompanies  it,  or,  in  rare  cases,  there  may  arise  a  peri-ure- 
thral  abscess  in  connection  with  urethral  chancroid.    Such  an  abscess 

*  Legendre  ("Memoire  sur  I'Herpes  de  la  Vulve,"  Archiv.  de  Med.,  1853)  has  brU- 
liantly  described  the  difiBculty  of  diagnosis  in  some  of  these  cases  in  the  female. 


478  cn.vNCROiD. 

opens,  furnishes  auto-inoculable  pus,  and  remains  fistulous  (Ricord, 
ll^lot). 

Successful  auto-inoculations  have  been  made  with  pus  derived  from 
irritated  syphilitic  chancre,  secondary  lesions,  especially  mucous  patch, 
or  in  suitable  subjects  may  sometimes  be  made  with  pus  from  gonor- 
rluva,  simple  abscess,  fluid  around  vegetations,  pus  from  a  pustule  of 
scabies,  etc.,  and  even  a  pustule  may  be  produced  by  simply  scratching 
the  skin  of  certain  individuals  with  a  clean,  new  lancet,  going  through 
the  motions,  but  inoculating  nothing.  Pustules  and  ulcerations  pro- 
duced by  any  of  these  methods  need  not  lead  to  error.  They  are  not 
chancroids,  and  never  have  been  proved  to  be  such,  through  their 
virulence  or  their  characteristic  intensity  shown  by  hetero-inoculation. 
And,  indeed,  even  in  the  first  inoculation  of  these  fluids,  the  chan- 
croidal ulcer,  as  above  described,  can  not  bo  produced.  An  ulcer,  in- 
deed, may  form,  and  an  ulcer  whose  pus  may  be  feebly  auto-inocula- 
ble, if  the  patient  be  in  a  condition  favorable  to  suppuration,  but  the 
pustule  is  usually  an  abortive  one,  tending  to  dry  up  and  scab,  the 
ulcer  is  small,  does  not  spread  like  chancroid,  nor  does  it  possess  the 
well-known  characteristics  of  the  latter.  Syphilitic  chancre  is  only 
auto-inoculable  after  it  has  been  irritated  and  made  to  suppurate  freely, 
and  so  of  the  other  substances  mentioned  above  ;  the  thicker  the  secre- 
tion is  in  pus-corpuscles,  the  more  likely  is  it  to  occasion  a  slight 
ulceration  by  auto-inoculation,  sustaining  Van  Roosbroeck's  theory  of 
the  contagious  properties  of  all  pus.  Then,  on  the  other  hand,  in 
certain  individuals,  any  scratch,  however  made,  will  fester  and  pro- 
duce pus,  but  it  would  be  difficult  to  confound  such  an  ulceration 
with  chancroid.  In  short,  these  cases  of  exceptional  auto-inoculability 
of  other  secretions  than  that  of  true  chancroid  will  rarely  lead  to 
error.  They  may  serve  to  feebly  ujDhold  preconceived  theories,  but 
not  to  deceive  the  earnest  searcher  after  truth.  The  real  error  to 
which  the  well-informed  student  is  exposed  is  that  of  inoculating 
from  the  secretion  of  a  chancroid  which  has  been  gangrenous,  and 
deciding  against  chancroid  because  the  inoculation  did  not  take,  and 
perhaps,  on  this  account,  concluding  that  his  patient  has  syphilitic 
chancre,  or  making  the  other  error  of  inoculating  from  a  mixed 
sore,*  and  wrongfully  deciding  that  there  is  no  syphilis  because  auto- 
inoculation  takes.  Hence  the  caution  to  be  remembered  :  chancroids 
attacked  by  total  gangrene  are  no  longer  inoculable,  and  an  ulcer 
reproducing  itself  by  inoculation  may  possibly  be  a  mixed  sore. 
Another  caution  is  equally  important :  only  practice  auto-inocula- 
tion of  a  phagedenic  chancroid  under  the  nipple  of  a  patient.  There 
is  always  a  chance  that  the  new  sore,  produced  upon  a  subject  already 
predisposed  to  phagedena,  may  itself  take  on  the  same  morbid  action, 

*  Inoculation  of  a  pre-existing  tubercle-papule,  or  sypliilitic  ulceration,  with  the  pus  of 
chancroid,  as  well  as  mixed  chancre,  should  be  remembered  as  possibilities. 


TREATMENT.  470 

but  the  chance  is  less  under  the  nipple  than  anywhere  else,  except  on 
the  face. 

Prognosis. — Chancroid  does  not  endanger  life,  except  very  occa- 
sionally, from  such  complications  as  severe  erysipelas,  or  extensive, 
sloughing  phagedena,  by  opening  a  vessel  or  exciting  peritonitis. 
Practically  it  may  be  said  that  chancroid  does  not  kill ;  even  the  im- 
mense chronic  ulcers  of  serpiginous  phagedena  eventually  get  well. 

Certain  results  of  chancroid,  however,  must  not  be  forgotten.  Ex- 
tensive cicatrices  left  hy  phagedena  may  prove  annoying  by  their  sub- 
sequent contraction,  and  the  actual  destruction  of  the  penis  by  phage- 
dena practically  unsexes  the  man.  Then  urethral  chancroid  is  inevi- 
tably followed  by  more  or  less  stricture  of  that  canal  at  the  seat  of  the 
lesion.  So,  also,  may  permanent  phimosis  be  produced  by  the  cica- 
trices of  chancroidal  ulcerations  at  the  orifice  of  the  prepuce.  Chan- 
croids of  the  pockets  on  either  side  of  the  frsenum  may,  but  very  rarely 
do,  eat  into  the  urethra,  and  result  in  artificial  hypospadias.  Exten- 
sive adhesions  of  the  prepuce  to  the  glans  penis  may  occur  after  chan- 
croidal phimosis,  as  indeed  after  the  simple  inflammatory  form. 


CHAPTER  II. 
GEAFCROID. 


Prophylactic  Treatment. — Local  Treatment  of  Chancroid. — Local  Treatment  of  Phagedena. — Gen- 
eral Treatment  of  Chancroid.— Bubo  ;  simple  ;  virulent. — Treatment  of  Bubo.— Lymphan- 
gitis ;  simple  ;  virulent ;  syphilitic. — Treatment  of  Lymphangitis. 

Prophylactic  Treatment. — As  a  rule,  chancroid  does  not  come  under 
the  surgeon's  notice  until  it  is  already  advancing  and  beyond  the  reach 
of  any  abortive  measures  other  than  actual  destruction  by  caustics. 
Bat,  on  the  other  hand,  it  not  infrequently  happens  that  a  crack  or 
abrasion  on  the  surgeon's  finger  becomes  inoculated  in  handling  chan- 
croids, and  then  any  prophylactic  treatment  short  of  caustics  becomes 
valuable.  Abortive  treatment  applied  to  chancroids  naturally  acquired 
is  not  as  effective  as  against  the  same  produced  artificially  by  inocula- 
tion. All  the  stronger  mineral  and  some  of  the  vegetable  acids,  caus- 
tic alkalies  and  certain  salts — as  the  sulphate  of  iron,  chromate  of  pot- 
ash, in  solution  in  water,  so  weak  as  not  to  attack  the  epidermis — 
prevent  the  development  of  the  chancroid  if  applied  over  the  artifi- 
cially inoculated  point  for  a  considerable  time — about  two  hours — 
within  a  period  of  three  to  six,  and  occasionally  twelve  to  twenty-four 
hours  after  inoculation  has  been  practiced  (Eollet).  The  longer  the 
time  which  has  elapsed  after  the  introduction  of  the  poison  the  longer 
must  the  preventive  solution  be  locally  applied  to  render  it  inactive, 


480  CDANCROID. 

ami,  naturally,  if  any  portion  (as  by  oblique  puncture)  has  been  intro- 
diiecd  beneath  the  e])idermis,  tliis  epidermis  must  be  removed  in  order 
to  allow  the  fluid  to  exert  its  power.  According  to  Rodet  and  Rollet, 
a  concentrated  solution  of  citric  acid  yields  the  best  results. 

Treatment  of  Chancroid. — Once  present  in  its  character  of  true 
chancroid,  no  treatment  yields  as  satisfactory  results  as  the  entire  de- 
struction of  the  ulcerated  surface  by  an  ethcient  escharotic,  thus  arti- 
ficially imitating  Nature,  which  sometimes  at  once  destroys  the  poison- 
ous character  of  the  sore  by  total  gangrene  of  the  secreting  surface. 
Any  active  caustic  may  be  used,  but  among  them  three  hold  the  most 
prominent  places,  as  being  easily  manageable  and  least  painful  ;  these 
three  are  :  nitric  acid,  sulphuric  acid,  and  the  actual  cautery.  The  lat- 
ter is  often  objectionable  as  greatly  exciting  the  patient's  fears,  but 
indeed  needlessly  so,  for  the  actual  cautery  is  perhaps  the  least  painful 
of  all  ;  the  idea,  however,  is  repulsive  to  a  patient.  The  caustic  alka- 
lies deliquesce  and  are  unmanageable,  besides  paining  more  than  the 
acids  ;  the  latter  remark  holds  good  of  the  Canquoin,  Vienna  paste, 
etc.  In  applying  a  caustic,  every  portion  of  the  sore  should  be  thor- 
oughly and  absolutely  destroyed,  and  all  existing  sores,  should  there 
be  more  than  one  ;  for,  should  any  ulcer  secreting  virus  be  left  active, 
it  will  speedily  reinoculate  the  raw  surfaces  left  by  the  separation  of 
the  eschars,  and  the  result  would  be  other  chancroids,  by  auto-inocu- 
lation, larger  than  those  first  operated  upon.  Hence  the  rule  :  If 
cauterization  be  decided  upon,  burn  every  portion  of  every  ulcer,  no 
matter  what  its  size.  If  there  be  subpreputial  chancroid,  with  phi- 
mosis, the  folly  of  of  burning  chancroids  of  the  preputial  rim  is  at  once 
obvious.  The  same  is  true  of  burning  sores  on  the  glans,  or  prepuce, 
if  urethral  chancroid  exist.  In  a^^plying  nitric  acid  it  is  well  to  use  a 
rather  blunt  glass  rod — a  pointed  one  sometimes  allows  the  acid  to  run 
off  in  a  drop,  flooding  too  freely  the  surface  to  be  used  on.  The  ulcer 
should  be  thoroughly  cleaned  and  dried  with  blotting-paper  slips.  A 
drop  of  pure  carbolic  acid  applied  and  then  absorbed  out  with  blotting- 
paper  makes  the  acid  application  less  painful.  Now  the  nitric  acid  is 
thoroughly  applied  and  left  on  until  a  white  rim  of  dead  tissue  extend- 
ing as  an  areola  about  the  ulcer  announces  that  the  base  of  the  latter 
is  destroyed.  Now  the  nitric  acid  is  dried  up  with  the  blotting-paper 
slips  and  the  surface  touched  with  liquor  potassae  to  neutralize  any 
excess  of  acid  there  may  be.  The  burned  surface  is  dressed  dry  with 
a  little  absorbent  cotton.  The  eschar  separates  in  a  few  days,  leaving 
a  healthy  ulcer,  which  heals  without  further  attention  than  cleanliness 
and  a  dry  dressing  in  a  few  days — or  a  longer  period  if  the  ulcer  has 
been  large  and  deep.  In  cauterizing  a  chancroid  under  a  tight  pre- 
puce, inflammatory  phimosis  may  come  on  unless  the  patient  be  kept 
at  rest  after  the  cauterization. 

Sulj)huric  acid   is  best  applied  as  the  carbo-sulphuric  paste  of 


TREATMENT.  4.^1 

Ricord.  This  is  formed  by  making  a  paste  of  ])uv(i  sulplmric  acid 
with  pulverized  vegetable  charcoal.  It  is  applied  upon  the  dried  sur- 
face of  the  sore,  and  pressed  down  into  all  its  inefjualities  with  a 
wooden  spatula.  It  dries  on  as  a  black  crust,  which  separates  after 
several  days  to  leave  a  healthy,  granulating,  simple  ulcer ;  or,  more 
rarely,  cicatrization  goes  on  to  completion  under  the  scab.  The  parts 
about  the  ulcer  must  be  protected. 

In  using  the  actual  cautery,  the  point  should  be  carried  down  into 
every  portion  of  the  ulcer  until  a  black  dead  eschar  of  the  whole  sur- 
face is  produced.  Cold-water  dressing  is  applied  afterward,  and  ano- 
dyne given  until  pain  has  ceased. 

All  chancroids  might  be  cured  by  this  simple  method  of  treatment, 
rest,  cold,  and  astringent  lotions  being  used  afterward,  to  combat 
inflammation.  Healing  chancroids,  however,  need  not  be  cauterized, 
nor  should  sores  of  the  meatus  urinarius  be  burned,  nor  very  extensive 
ulcerations,  except  as  a  last  resource,  nor  chancroids  which  are  largely 
multiple,  both  on  account  of  the  uncomfortable  degree  of  inflamma- 
tion apt  to  be  provoked,  and  the  greater  liability  to  leave  some  little 
secreting  surface  undestroyed,  which  may  reinoculate  the  burned  sur- 
faces. Much  pain  may  be  spared  the  patient  by  the  free  use  of  a 
strong  solution  of  hydrochlorate  of  cocaine  before  he  is  burned.  The 
direct  combination  of  cocaine  with  nitric  acid  is  of  no  use.  I  have 
tried  it  at  all  strengths.  A  chancroid  to  be  burned  most  effectively  must 
be  burned  early.  If  the  ulcer  has  lasted  only  a  few  days,  one  thorough 
cauterization  cures  it.  If  the  ulcer  is  already  several  weeks  old  (and 
not  phagedenic)  it  will  in  many  instances  get  well  as  quickly  under 
iodoform,  calomel,  or  other  dressing,  as  it  will  by  being  cauterized. 
The  older  the  ulcer  (unless  it  is  already  healing,  under  which  circum- 
stances cauterization  is  out  of  the  question)  the  more  thoroughly  must 
the  caustic  be  applied  to  be  efficient.  It  is  never  wise  to  depend  upon 
nitrate  of  silver  for  caustic  purjDOses.  It  does  harm,  since  its  caustic 
action  does  not  extend  deeply  enough,  and  superficial  cauterization 
always  makes  matters  worse.  When  it  is  unadvisable  to  use  caustic,  or 
when  the  patient  refuses  to  submit  to  the  application,  the  surgeon  is 
still  possessed  of  remedies  suitable  to  the  disease. 

It  is  well  to  remember  that  greasy  local  applications  to  chancroids 
are  bad.  They  become  rancid,  and  prevent  the  escape  of  the  poison- 
ous pus.  Mercurial  ointment  is  believed  by  Eicord  to  be  of  all  the 
most  harmful.  I  have  tried  salicylic  acid,  recently  suggested.  It 
has  always  failed  me.  Perhaps  the  best  treatment  for  simjjle,  uncom- 
plicated chancroid,  when  not  destroyed  by  caustic,  is  to  cover  the  en- 
tire surface  with  powdered  iodoform.*  The  local  action  of  this  drug 
in  chancroid  is  superior  to  anything  short  of  cauterization,  but  there 

*  For  toxic   local   and  systemic  effects  of  iodoform,  consult  Taylor,  "X.  Y.  Med. 
Jour.,"  Oct.,  1887. 
31 


482  CHANCROID. 

are  two  objections  to  its  use,  namely,  complaint  of  pain  occasionally 
from  sensitive  patients,  which  can  be  controlled  by  cocaine,  and  the 
far  more  serious  objection,  the  disagreeable  odor  of  the  drng.  Noth- 
ing so  far  discovered  covers  this  effectively — ether,  tonka-bean,  balsam 
of  Pern  are  not  satisfactory.  The  best  means  we  have  of  disguising 
the  odor  is  mixing  the  jiowdered  iodoform  with  one  third  of  tinely- 
powdered,  freshl3'-ground  cotlee.  Cleanliness  is  of  the  first  impor- 
tance, lodol  has  no  value  in  my  hands.  A  good  expedient  is  dust- 
ing the  surface  with  dry,  ]xiwdered  oxide  of  zinc,  or  calomel  with  a 
little  camphor,  or  bismuth,  and  covering  the  whole  with  lint  soaked 
in  a  "weak  solution  of  aromatic  wine,  one  part  to  thl-ee  of  water,  or 
alcohol,  one  part  to  two  of  water,  or  permanganate  of  potash,  gr.  j-ij 
to  the  3  j,  or  carbolic  acid,  one  half  of  one  per  cent.  It  is  sometimes 
useful  even  to  large  surfaces  to  apply  pure  cai-bolic  acid  every  other 
day,  or  a  solution  of  bromine,  3  ij  to  the  3  j,  dressing  between-timcs 
■with  one  of  the  above  solutions.  Such  dressings  should  be  frequently 
changed,  as  cleanliness  is  of  the  first  importance.  In  the  treatment 
of  any  chancroid,  especially  such  as  are  situated  near  the  fra^num, 
■where  the  lymphatics  are  most  abundant,  rest  is  of  the  greatest  utility 
in  preventing  inflammation  and  the  formation  of  suppurating  bubo. 
For  chancroid  of  the  meatus,  nothing  is  better  than  a  little  plug  of 
dry  lint,  sprinkled  with  iodoform,  and  patience,  with  an  alkaline 
diuretic,  to  render  the  urine  less  irritating,  and  the  absolute  avoid- 
ance of  any  sexual  excitement  or  erotic  thoughts  calculated  to  stimu- 
late erection.  Urethral  chancroid  may  be  benefited  by  the  same  gen- 
eral means  and  the  occasional  injection  of  a  mild  solution  of  aromatic 
■wine  in  warm  water. 

Sulpreputial  cliancroid  requires  no  modification  in  treatment, 
unless  there  be  congenital  or  inflammatory  phimosis.  The  prepuce, 
however,  should  not  be  dressed  back,  for  fear  of  paraphimosis.  With 
phimosis  frequent  injections  of  the  balano-preputial  cul-de-sac  with 
Avarm  water  are  necessary  for  cleanliness,  and  to  prevent  the  pus  from 
accumulating  and  burrowing.  After  the  washing,  any  of  the  above- 
mentioned  stimulating  lotions  may  be  injected,  or  a  gr.  v-xv  solution 
of  the  nitrate  of  silver  (Ricord),  which,  according  to  this  surgeon,  acts 
also  as  a  local  anaesthetic.  The  injection  of  iodoform  shaken  up  with 
balsam  of  Peru  is  suitable  for  these  cases.  It  is  often  wiser  in  these 
cases  from  the  first  to  cut  the  prepuce  freely  open  by  two  lateral  in- 
cisions, and  thoroughly  cauterize  everything  in  a  state  of  ulceration, 
excoriation,  or  rawness,  dressing  open.  It  looks  more  harsh,  but  in  the 
end  may  prove  more  kind.  The  Pafiuelin  cautery  is  a  suitable  agent 
to  deal  with  the  cut  surfaces  under  these  circumstances. 

For  simple  or  erysipelatous  inflammation  of  chancroid,  the  best 
treatment  is  absolute  rest,  and  an  elevated  position  of  the  organ,  aided 
perhaps  by  a  lotion  of  lead-water  externally.     Where  the  inflamma- 


TREATMENT.  4§3 

tioii  runs  high,  with  phimosis,  and  the  tension  of  tlie  prepuce  becomes 
very  great,  it  should  be  slit  up  on  the  dorsum,  or  entirely  cut  away 
(circumcision)  if  it  be  very  redundant.  When  the  pus  issuing  from 
beneath  the  inflamed  prepuce  begins  to  smell  bad,  the  indication  is 
to  cut  at  once  to  avert  gangrene  or  phagedena. 

In  the  treatment  of  chancroid  it  is  always  advisable  to  keep  the 
ulcerated  surfaces,  if  possible,  covered  with  lint  or  some  substitute,  to 
absorb  the  pus  as  it  flows,  and  protect  the  parts  which  would  other- 
wise lie  in  contact  with  the  diseased  surface  and  run  the  risk  of  inocu- 
lation. 

In  anal  cliancroid  the  merits  of  each  case  must  decide  whether  it 
is  allowable  to  employ  actual  cautery.  The  greater  the  amount  of 
tissue  destroyed,  the  greater  the  degree  of  subsequent  stricture.  If  an 
infected  fistulous  tract  exists  in  connection  with  any  chancroid,  the 
latter  should  not  be  cauterized  unless  the  former  can  be  slit  up  and 
similarly  dealt  with. 

Gangrene  not  phagedenic  should  be  left  unmolested.  The  fall  of 
the  slough  may  be  hastened  by  the  application  of  a  iDoultice  of  camo- 
mile-flowers, with  charcoal,  or  a  little  permanganate  of  jDotash  or  liquor 
sodse  chlorinatge  added  as  a  disinfectant,  or  yeast.  Simple  dressings 
for  the  healthy  ulcer  beneath  are  all  that  is  required. 

Cliancroid  of  the  pochets  beside  the  frcenum  frequently  undermine 
the  latter,  which,  when  very  thin,  may  be  accidentally  ruj)tured,  giv- 
ing rise  sometimes  to  considerable  hgemorrhage  from  the  artery  of  the 
fr£enum.  To  anticipate  this,  it  is  advisable  to  pass  a  double  thread 
beneath  the  fraenum,  and  tie  both  ends,  letting  the  ligatures  cut 
through.  Where  the  prepuce  is  short,  and  there  is  much  oedema 
about  the  frsenum,  loolving  toward  paraphimosis,  the  repeated  judi- 
cious application  of  collodion  to  the  swollen  skin  (after  drying  it)  may 
prevent  the  latter  complication. 

Where  paraphimosis  has  come  on,  if  it  is  reducible,  or  irreducible, 
without  strangulation,  absolute  rest,  collodion,  and  evaporating  lotions 
are  called  for  ;  if  there  be  irreducible  paraphimosis  with  strangulation, 
the  knife  must  be  used  to  avoid  gangrene. 

Local  Treatment  of  Phagedena. — The  proper  local  treatment  for 
phagedena  is  total  destruction  of  the  base  of  the  ulcer  and  a  sufficient 
depth  of  the  tissue  around.  This  may  be  effected  in  a  variety  of  ways. 
Scraping  thoroughly  with  a  sharp  curette  under  ether,  and  then  apply- 
ing a  deliquesced  solution  of  crystals  of  chloride  of  zinc  or  nitric  acid 
to  the  scraped  area  after  stopping  the  oozing  is  an  excellent  means. 
Nitric  acid  alone  seldom  suflSces.  The  carbo-sulphuric  paste  works 
admirably  here.  The  actual  cautery  is  not  in  my  opinion  as  good  a 
means  as  surgical  scraping  aided  by  an  ordinary  caustic,  as  suggested 
above.  In  any  kind  of  local  surgical  treatment  all  bridges  of  skin 
must  be  clipped  away,  all  sinuses  slit  up  thoroughly,  all  glands  lying 


4S4  CHANCROID. 

in  the  ulcerated  space  and  islands  of  irrejrular  <rrannlation  tissue  re- 
moved. It  is  better  to  be  too  thorough  the  first  time  in  destroying 
than  to  have  to  repeat  the  operation  after  relapse.  Tiiis  relapse  after 
local  treatment  is  unfortunately  not  phenomenally  uncommon.  Tiie 
indication  for  a  second  cauterization  is  furnished  by  the  Jieneral  ap- 
pearance of  the  ulcer,  or  a  return  of  the  old  jiain,  so  ciiaracteristic  of 
advancing  phagedena,  and  which  ceases  after  thorough  cauterization. 
Erysipelas  or  other  inllammatory  complication  is  rarely  lighted  up  by 
cauterization,  an  operation  which,  though  severe  in  appearance,  the 
exjierienced  surgeon  learns  to  regard  with  increasing  favor. 

When  phagedena  has  attacked  a  virulent  bubo  in  the  groin,  and  in 
the  large  ulcer  are  found  several  lymphatic  glands,  undestroyed  by  the 
phagedena,  riding  out  from  its  base,  it  is  better  to  remove  these  before 
resorting  to  cauterization. 

Sometimes  these  active  local  means  can  not  be  employed,  as  where 
large  vessels  are  exposed  by  the  ulceration,  when  long  and  deep  fistulaB 
exist  which  can  not  be  thoroughly  or  safely  acted  upon,  when  the 
ulcer  is  exceedingly  large,  and  the  patient's  condition  will  not  warrant 
the  application  of  caustic  to  so  extensive  a  surface.  Here  Thiersch's  * 
suggestion  might  be  tried,  the  subcutaneous  injection  of  a  solution  of 
nitrate  of  silver  in  water,  1  in  1,500,  about  the  phagedenic  zone,  the 
injections  being  one  centimetre  apart,  and  one  cubic  centimetre  being 
injected  at  each  point  of  puncture.  Chloroform  must  be  used  for  pain, 
and  ice  afterward.  I  have  no  personal  knowledge  of  this  remedy.  For 
such  cases  Eicord  considers  a  solution  of  the  tartrate  of  iron  and  potash 
(gr.  xx-xl  to  the  ounce)  appropriate.  Carbolic  acid  alone  has  not  satis- 
fied me.  I  have  not  tried  Vidal's  f  suggestion  of  pyrogallic  acid,  five 
per  cent,  powder  or  ointment,  applied  twice  daily  until  the  character  of 
the  sore  changes.  Bumstead  mentions  some  successful  cases  by  Hinkle 
from  the  use  of  permanganate  of  potash  ( 3  j  i5  to  the  3  j),  j^ut  on 
every  two  hours,  a  solution  of  gr.  x  to  the  pint  being  constantly  ap- 
plied. Iodoform  in  powder  is  an  excellent  local  application  for  phage- 
dena. Erysipelas  complicating  phagedena  sometimes  on  retiring  leaves 
the  ulcer  in  a  healthy  condition  of  repair. 

Phagedena  of  the  anus  and  rectum  should  be  scraped  and  cauter- 
ized when  all  the  surfaces  involved  can  be  thoroughly  treated,  other- 
wise the  parts  must  be  kept  clean  and  separated  by  iodoform  dressings, 
enemata  being  used  for  each  intestinal  evacuation.  The  worst  cases 
call  for  colotomy.  Bridge  J  reports  an  admirable  success  by  this 
method. 

When  either  the  condition  of  the  parts  or  that  of  the  patient  con- 
tra-indicate  sufficiently  radical  local  treatment,  we  may  still  have  re- 

*  "Centralblatt  f.  Chir.,"  No.  27,  1882. 

f  "  Bull.  Gen.  dc  Tli6rap.,"  January  30,  1883,  p.  501. 

j  "Archives  of  Dermatology,"  January,  1876,  p.  122. 


TREATMENT.  435 

course  to  an  excellent  local  means  of  treatment  formerly  advocated  by 
Ilebra  in  Germany,  Hutchinson  in  England,  Ilemard  in  France,  and 
more  recently  by  Arthur  Cooper*  in  England,  namely,  prolonged 
immersion  of  the  affected  parts  in  hot  water,  a  uniform  temperature 
as  near  98°  Fahr.  as  possible  being  maintained — that  is,  for  eight  to 
ten  hours  a  day — the  parts  being  dusted  with  iodoform  between  times. 
Of  Cooper's  thirty-one  cases,  twenty-two  were  sloughing  or  phage- 
denic ulcers,  and  in  most  of  them  the  ulcer  became  healtliy  in  from 
two  to  six  days.  Chauveau's  f  investigations  bear  upon  this  point. 
He  found  that  chancroidal  pus  heated  to  38°  Cent,  would  not  take 
when  inoculated. 

General  Treatment  of  Chancroid. — Chancroid  is  a  local  ulcer.  It 
does  not  in  any  manner  affect  the  constitution,  but  the  constitution  of 
the  individual  affects  it,  rendering  it,  perhaps,  very  slow  and  chronic 
in  its  course ;  or,  from  personal  idiosyncrasy,  phagedenic.  Simple 
chancroid,  then,  requires  no  internal  treatment,  except  such  as  is  sug- 
gested by  common  sense  and  general  hygiene.  Chronic  sluggish 
cases,  which  fail  to  respond  to  local  treatment  unless  the  trouble  lies 
in  the  mechanical  irritation  of  motion,  may  be  brightened  ujd  and 
started  toward  cure  by  all  known  tonic  means  ;  among  which,  change 
of  air,  cod-liver  oil,  and  preparations  of  iron  hold  the  first  rank. 
Phagedena  being  nearly  always  a  constitutional,  individual  tendency, 
requires  the  active  use  of  the  last-named  means,  with  good  food,  and 
perhaps  wine.  Kicord  speaks  highly  of  the  tartrate  of  iron  and  potash 
internally.  It  may  be  given  in  gr.  xx  doses.  Rodet  praises  large 
doses  of  opium  as  a  means  of  cure. 

{n)  Bubo  {^ov/Sw,  groin)  is  a  term  which  originally  applied  only 
to  certain  morbid  conditions  of  the  glands  of  the  groin.  It  has,  by 
modern  usage,  been  adopted  for  inflammations  or  simj^le  enlargements 
of  these  organs  occurring  anywhere  in  connection  with  lesions  usually 
but  not  necessarily  venereal.  There  are  three  distinct  varieties  of 
bubo  :  the  simple  inflammatory,  including  all  the  previous  stages  of 
engorgement ;  the  virulent,  the  pus  of  which  is  auto-inoculable,  pro- 
ducing chancroid ;  and  the  syphilitic.  Of  these,  the  second  is  and 
can  be  found  in  connection  with  no  other  conceivable  lesion  than  chan- 
croid. Its  presence  is  absolute  proof  of  the  pre-existeuce  of  that  form 
of  ulcer.  Syphilitic  bubo,  on  the  other  hand,  can  not  exist  unless  the 
patient  have  syphilis.  Simple  inflammatory  bubo,  very  common  with 
chancroid,  occurs  also  sometimes  with  any  inflammatory  lesion,  gon- 
orrhoea, syphilitic  chancre  occasionally,  herpes,  balanitis,  or  indeed 
may  develop  spontaneously.  Pure  syphilitic  bubo  does  not  suppurate, 
simple  bubo  usually  does,  but  may  not ;  virulent  bubo  necessarily  does. 
Syphilitic  bubo  will  be  considered  in  connection  with  syphilis. 

*  London  "Lancet,"  May  24,  1879,  p.  1Z1. 
f  "  Lyon  Medicale,"  August  12,  1883. 


486  CHANCROID. 

The  diap:no?is  of  bubo  is  simiililkHl  by  its  arrangement  in  tlic  PiAG- 
xosTic  Table,  Chapter  IV. 

Bubo  does  not  necessaril}'  occur  in  the  groin.  It  appears  in  glands 
which  receive  the  lymphatic  trunks  distributed  to  that  portion  of  the 
body  where  the  exciting  cause  (clunicroid)  occurs.  It  may  be  found  in 
the  axilla,  in  the  epitrochlear  gland,  under  the  jaw,  or  elsewhere.  It 
is  most  frequently  encountered  in  the  groin,  because  its  exciting  cause 
is  usually  situated  on  the  penis.  Bubo  is  more  common  in  the  male 
tlian  in  the  female.  Fournier  believes  that  it  occurs  with  chancroid, 
about  once  in  three  cases.  The  ]iroportion  between  simi)le  and  viru- 
lent bubo  is  unknown,  as  no  statistics  have  been  compiled.  Simple 
bubo  is  hapi>ily  more  common.  The  most  usual  seat  of  bubo  is  in  the 
central  gland  or  glands  of  the  inguinal  chain,  those  lying  over  the 
great  vessels.  Bubo  is  single  or  double,  usually  on  the  same  side  with 
the  lesion  (chancroid)  or  on  the  other  side  (crossed)  or  double  for  a 
single  sore  ;  sometimes  in  double  bubo,  simple  bubo  will  exist  on  one 
side  and  virulent  on  the  other.  Bubo  only  affects  the  first  group  of 
glands  receiving  the  lymphatics  from  a  part ;  there  is  no  implication 
of  glands  farther  on,  either  in  the  case  of  simple  or  virulent  bubo. 
Bubo,  simple  (sympathetic  or  inflammatory)  or  virulent,  may  appear 
earlv  or  late  in  the  course  of  chancroid,  even  after  the  latter  is  nearly 
or  quite  healed.  Simple  bubo  usually  appears  earlier  (before  the  thir- 
teenth day,  llairon  *)  than  virulent  bubo,  although  the  latter,  when 
it  does  commence,  advances  more  rapidly.  Puche  f  saw  a  virulent 
bubo  come  on  after  three  years'  duration  of  a  serpiginous  chancroid. 
Both  forms  of  bubo  are  a  little  more  commonly  found  with  chancroid 
near  the  fraenura,  where  the  lymphatics  are  numerous  and  large.  Both 
forms  may  be  attended  by  granulations  upon  the  ulcerated  surface,  con- 
stituting so-called  vegetating  bubo. 

Simple  Bubo. — This  is  the  form  commonly  known  as  sympathetic 
bubo.  It  is  essentially  the  same  inflammatory  glandular  swelling  as 
occurs  after  vaccination,  or  from  an  inflamed  corn.  Any  inflamma- 
tory lesion  of  the  penis  may  be  accompanied  by  such  a  bubo  (single  or 
double)  in  the  groin.  Chancroid  is  the  most  common  exciting  cause, 
and  especially  chancroids  which  are  inflamed.  Bubo  may  occur  with- 
out any  visible  causing  lesion. 

Symptoms. — The  patient  in  walking  feels  a  little  pain  in  the  groin, 
and  thinks  he  has  ''strained"  himself.  On  examination,  he  finds  a 
small,  oval  swelling,  perfectly  movable,  under  the  skin,  but  painful  on 
pressure.  If  properly  managed,  this  may  extend  no  farther,  but  usu- 
ally the  lump  gradually  grows.  It  becomes  adherent  to  the  skin  at 
one  or  more  points.  The  cuticle  grows  red,  feels  thick  and  porky, 
perhaps  gets  cedematous  ;  finally,  a  central  spot  of  softening  may  be 
detecte<B|  the  skin  becomes  thin  and  shining ;  the  bubo  at  last,  like 
*  Quoted  by  Rollct.  f  Ricord,  "  Le90ns  sur  le  Chancre."     Fournier. 


SIMPLE   BUBO— VIRUMXT   BUBO.  437 

uny  other  glandular  abscess,  bursts,  discharges  a  creamy  pus,  and,  after 
flowing  for  a  few  days  or  weeks,  gradually  contracts  and  gets  well. 
The  healing  of  bubo  is  very  apt  to  be  indefinitely  j^ostponed,  in  conse- 
quence of  the  motion  to  which  the  part  is  necessarily  subjected  in 
walking,  every  step  opening  the  wound,  and  pulling  upon  the  young 
granulations  which  are  vainly  trying  to  fill  the  cavity  left  by  suppura- 
tion. Especially  is  this  the  case  in  feeble,  broken-down  constitutions, 
sickly  youths,  and  those  who  persist  in  drinking.  Suppuration  of 
simple  bubo  does  not. necessarily  occur,  and  at  any  period,  even  after 
matter  is  formed,  resolution  is  possible,  but  the  majority  open  in  spite 
of  all  efforts. 

While  abscess  is  forming,  the  ordinary  constitutional  symptoms 
exist.  Pain,  generally  present,  is  sometimes  wanting,  but  always  in- 
creases as  ulceration  becomes  imminent,  and  is  generally  greatly  aggra- 
vated by  motion.  The  formation  of  pus  is  frequently  announced  by 
chill,  and  attended  by  febrile  phenomena. 

Now,  this  simple  glandular  abscess  is  subject  to  variations  in  its 
course.  With  strumous  patients,  usually  several  glands  swell  on  both 
sides,  and  become  matted  together  into  a  vast  lump.  These  grow 
slowly,  often  without  pain.  They  are  particularly  sluggish,  and  show 
very  little  tendency  to  suppurate.  Their  pressure  inflames  the  skin, 
which  may  get  red,  thick,  porky,  often  threatening  ulceration  at  dif- 
ferent points.  The  return  circulation  from  the  scrotum  and  penis  is 
often  obstructed,  leading  to  oedema  of  these  parts.  Finally,  the  in- 
flamed tissues  around  the  glands  break  down  into  pus,  which,  when 
discharged,  is  thin,  watery,  sanious.  The  breaking  of  the  abscess 
under  these  circumstances  does  not  materially  diminish  the  size  of  the 
tumor,  for  the  periglandular  tissue  has  suppurated,  and  not  the 
glands.  The  skin  now  gets  thinned  over  the  swelling,  the  opening 
from  which  the  pus  was  discharged  enlarges,  jDerhaps  one  of  the  glands 
breaks  down  into  suppuration,  or  it  may  protrude  through  the  open- 
ing, covered  by  pale,  flabby  granulations.  The  pus  may  burrow  along 
the  groin,  over  the  crest  of  the  ilinm,  down  the  thigh,  over  the  abdomen, 
into  the  scrotum,  and  new  abscesses  form  at  the  blind  ends  of  these 
canals,  which  opening,  fistulous  tracts  are  left,  marked  by  a  hard, 
cordy  feel  under  the  skin.  The  discharge  of  serous  pus  from  these 
fistulaB  continues  sometimes  interminably.  Instead  of  suppurating, 
strumous  bubo  may  remain  for  months  in  a  condition  of  almost  jDain- 
less,  indolent  enlargement. 

Again,  simple  bubo  may  be  complicated  by  erysipelas  or  gangrene, 
but  probably  never  by  phagedena. 

The  pus  of  simple  bubo  is  not  auto-inoculable. 

ViEULENT  Bubo. — This  form  is  often  known  as  the  bubo  of  absorp- 
tion, since  some  of  the  peculiar  chancroidal  poison  must  be  absorbed 
in  order  to  produce  it,  whether  by  ulceration  into  a  lymphatic  trunk 


4S8  CHANCROID. 

or  by  migration  of  pns-corpiiscles  is  unknown.  Witliout  chancroid 
its  existence  is  impossible.  Virnlent  bubo  is  usuallj'  single,  in  one 
gland,  on  one  side.  It  suppurates  necessarily,  but,  until  it  is  02ien, 
there  is  no  diagnostic  feature  which  can  positively  distinguish  it  from 
simple  acute  inflammatory  bubo  on  the  road  to  suppuration.  This 
only  can  be  said,  that  its  course  is  more  rai>i(l,  more  acute,  more  in- 
flammator}".  Periadenitis  occurs  with  virulent  bubo  also,  the  juis 
forming  outside  the  gland  usually  ulcerating  through  the  skin  first. 
In  such  case  the  first  pus  that  flows  is  simple,  not  poisonous,  and  the 
wound  looks  like  that  seen  with  simple  bubo  ;  but  soon  the  deeper  pus 
from  the  gland  appears,  poisons  the  wound,  and  gives  it  the  well- 
known  chancroidal  aspect,  and  now  the  pus  is  freely  auto-inoculable. 
Virulent  bubo  may  discharge  by  a  single  opening.  I'his  is  large  at 
first,  and  subsequently  enlarges,  but,  if  fortunately  adhesive  inflam- 
mation has  agglutinated  its  edges  to  the  surrounding  underlying  tissue, 
no  further  poisoning  takes  place,  the  abscess  assumes  all  the  character 
of  a  true  chancroid  (abrupt  edges,  pultaceous,  irregular  base),  passes 
through  its  regular  stages,  and  finally  gets  well.  Matters  do  not, 
howevei',  always  eventuate  so  fortunately ;  the  thinned  skin  over  the 
suppurating  gland  may  fail  to  become  bound  down  by  adhesive  inflam- 
mation, or  to  give  way  speedily  at  a  single  point,  then  the  pus  under- 
mines a  certain  extent  of  integument,  and  perforates  it  in  a  cribriform 
manner.  Burrowings,  more  or  less  extensive,  go  on.  Hard,  sinuous, 
everted  edges,  overhanging  flaps  and  bridges  of  thin,  purj)lish  skin, 
long  fistulous  tracts,  and  poisoned  pouches  full  of  jras,  serve  indefi- 
nitely to  prolong  the  virulent  bubo,  making  its  duration  a  matter  of 
months,  perhaj^s  years. 

Finalh",  virulent  bubo,  like  any  other  chancroid,  may  be  attacked 
by  phagedena,  or  any  of  the  other  complications  set  down  for  chan- 
croid. Accidental  auto-inoculation  of  the  skin  of  the  abdomen  or 
thigh  is  not  uncommon.  The  worst  forms  of  phagedena  are  seen 
in  connection  with  virulent  bubo.  The  case  which  Fournier  records 
as  having  lasted  fourteen  years  and  being  still  unhealed  at  the  knee 
w'as  phagedena  of  a  virulent  bubo.  All  the  varieties  of  phagedena, 
are  found,  but  the  pultaceous,  serpiginous  variety  is  most  common. 
It  usually  travels  up  over  the  abdomen,  but  if  very  extensive  seems 
to  prefer  to  turn  the  flank  and  go  down  the  thigh,  rather  than  ad- 
vance upon  the  chest,  that  region  shown  by  Boeck  to  be  unfavor- 
aVjle  soil  for  chancroid.  Phagedena  does  occur  on  the  chest,  but  not 
commonly. 

The  nature  and  character  of  phagedena  have  been  described.  A 
phagedenic  bubo  does  not  necessarily,  or  indeed  usually,  exist  in  con- 
nection with  a  phagedenic  chancroid,  wiiicli  latter  maybe  attended  by 
simple  bubo,  or  leave  the  glands  untouched  ;  nor  is  lymphangitis 
necessary,  or  indeed  common.      An  insignificant-looking  chancroid 


TREATMENT   OF   BUBO.  439 

may  be  attended  by  a  phagedenic  bubo,  and  phagedenic  cliancroid 
may  have  no  bubo  at  all. 

riorteloup*  has  a  case  going  to  show  that  the  virus  of  chancroid 
may  be  long  retained  in  the  glands  of  the  groin  before  showing  itself. 
A  patient  of  twenty-six  has  chancroid  in  February,  1879,  and  shortly 
suppurating  bubo.  The  latter  is  lanced,  and  the  patient  leaves  hospi- 
tal April  15th,  with  chancroid  well  and  no  swelling  in  either  groin. 
Six  months  later,  having  meantime  had  no  new  sore,  he  returns  with 
glands  swollen  in  each  groin,  and  three  and  a  half  months  later  he 
again  entered  hospital,  both  groins  suppurating,  one  phagedenic.  This 
case  is  so  irregular  as  to  need  confirmation,  in  my  opinion. 

Diagnosis. — The  diagnosis  between  simple,  virulent,  and  syphilitic 
bubo  will  be  found  in  the  diagnostic  table  following  syphilitic  chancre. 
The  hubon  (TembUe  does  not  exist  in  the  sense  originally  attributed  to 
the  term  ;  namely,  a  bubo  without  antecedent  venereal  ulcer,  ushering 
in  syphilis,  and  furnishing  auto-inoculable  pus.  The  absurdity  of  this 
is  self-evident,  for  a  virulent  bubo  never  ushers  in  syphilis,  nor  indeed 
has  it  anything  to  do  with  that  disease.  It  is  nothing  more  or  less 
than  a  chancroid.  A  bubo,  however,  may  suj)purate  in  the  groin 
without  necessarily  any  antecedent  chancroid,  as  in  connection  with 
herpes,  gonorrhcea,  balanitis,  an  inflamed  corn  ;  or  spontaneously,  as 
may  a  gland  in  the  neck  or  axilla  ;  such  a  bubo,  however,  does  not 
furnish  poisonous  pus.  When  a  gland  in  the  groin  suppurates,  and  its 
pus  is  virulently  and  actively  auto-inoculable,  it  has  been  preceded  by 
a  chancroid.  The  latter  may  have  cicatrized  before  the  patient  presents 
himself,  perhaps  was  situated  in  the  urethra,  or  even  in  the  rectum, 
but  somewhere  it  is  or  certainly  has  been.  The  intelligence  of  the 
surgeon  may  occasionally  be  taxed  to  find  it. 

There  are  no  diagnostic  signs  between  a  simple  and  virulent  bubo 
at  first.  When  opened  spontaneously  or  by  art,  the  outlet  does  not 
enlarge  in  simple  bubo  ;  in  virulent  bubo  it  does,  and  shows  all  the 
characteristic  marks  of  chancroid.  Again,  if  suj^puration  can  be 
arrested  in  an  inflamed  gland,  it  must  have  been  simple  bubo  (unless 
syphilitic)  ;  virulent  bubo  must  necessarily  suppurate. 

Treatment  of  Bubo. — The  preventive  treatment  of  bubo  is  rest, 
and  the  avoidance  of  such  causes  as  tend  to  inflame  the  chancroid. 
The  most  positive  preventive  treatment  is  the  absolute  destruction  of 
the  chancroid  with  caustic.  In  such  a  case  if  the  simple  ulcer  left  by 
the  fall  of  the  slough  is  still  able  to  excite  a  simple  bubo,  yet  virulent 
bubo  and  its  attendant  phagedena  can  no  longer  occur.  Tincture  of 
aconite  and  belladonna  combined  in  equal  parts  are  of  some  use  locally, 
especially  if  combined  with  rest.  Tincture  of  iodine  I  consider  abso- 
lutely useless  if  not  harmful  in  acute  advancing  bubo,  and  I  no  longer 
employ  it.     Eest  in  bed,  aconite  and  belladonna,  and  a  light  poultice 

*  "Ann.  de  Derm,  et  de  Syph.,"  January,  1880,  p.  54. 


490  CUANCROID. 

will  avert  impoiulinfj  bubo  (sinii)lc)  more  often  than  an}-  means  with 
which  I  am  ac([uainti.'d. 

Besides  rest,  there  are  tliroe  other  agents  which  may  avert  suppura- 
tion occasionally  : 

1.  Blistbr,  repeated  as  soon  as  the  skin  has  re-formed. 

2.  Pressure,  wliich.  if  ajiplied  early  and  judiciously  in  mild  cases, 
is  sometimes  elfective. 

3.  Leeches,  plentifully  applied  around  the  swollen  gland. 

The  latter  treatment  is  only  applicable  in  the  early  stages  of  bubo, 
for,  should  the  swelling  prove  virulent,  suppuration  is  inevitable,  and, 
if  the  leech-bites  are  near  the  point  of  opening  and  have  not  cicatrized, 
they  are  pretty  sure  to  become  inoculated  and  form  so  many  chancroids. 
If  the  tendency  to  suppuration  advances  very  slowly,  the  bubo  is  cer- 
tainly simple  ;  if  rapidly,  large,  hot  poultices  should  be  constantly 
applied  to  hasten  it,  and  the  abscess  may  be  allowed  to  open  itself ; 
but,  if  from  its  very  rapid  course  it  is  believed  to  be  virulent,  an 
opening  should  be  made  as  soon  as  any  fluctuation  can  be  felt,  to  let 
out  the  poisonous  pus,  and  save  destruction  of  tissue.  In  this  way 
burrowing  may  be  averted,  as  it  may  also  by  properly  applied  pressure. 
It  is  a  good  rule  to  open  early  in  any  case.  If  it  be  simjile  bubo,  no 
harm  is  done  ;  if  it  be  virulent,  the  chancroidal  ulcer  following  is  by 
so  much  less  extensive.  Small  collections  of  pus  should  be  punctured, 
large  ones  extensively  laid  open.  If  the  skin  does  not  appear  to  be 
adherent,  some  caustic  paste  may  be  preferred  to  incision.  If  any 
outside  wounds  exist  (leech-bites)  at  the  time  of  opening  bubo,  they 
should  be  carefully  protected. 

The  question  of  attempting  to  abort  the  bubo  after  suppuration  is 
imminent  or  has  actually  occurred  is  worth  considering.  Morse  K. 
Taylor  *  gives  a  number  of  interesting  cases  of  acute  inflammation  in 
lymphatic  glands,  in  which  he  claims  to  have  invariably  aborted  suppu- 
ration by  injecting  into  their  substance  twenty  minims  of  a  solution 
of  carbolic  acid  (gr.  viij  to  the  3  j).  If  suppuration  has  occurred,  he 
aspirates  the  cavity,  and  washes  on  successive  days  with  a  carbolic-acid 
solution  (gr.  xij  to  3  j).  Tiiere  is  certainly  no  objection  to  trying  a 
means  so  simple. 

When  the  knife  is  used,  if  the  bloody,  thinnish,  unhealthy  look  of 
the  i^us  suggest  virulent  bubo,  the  poultice  should  be  discontinued, 
otherwise  it  is  better  kept  up  for  some  days.  All  cavities,  if  large, 
should  be  thoroughly  cleansed  several  times  daily  with  warm  water, 
and  then  injected  with  a  mild  solution  of  carbolic  acid  or  permanga- 
nate of  potash,  dilute  alcohol,  or  some  other  detergent  lotion.  After 
virulent  bubo  becomes  an  open  ulcer,  its  treatment  is  that  of  chan- 

*  He  used  a  solution  of  1  in  30,  and  injected  in  this  way  at  one  sitting,  in  different 
parts  of  a  single  gland  the  size  of  a  goose-egg,  gr.  xv  of  potassium  iodide  in  |  j  of  water, 
j^nd  repeated  the  injections  four  times  in  two  days,  he  says,  with  success. 


LYMPHANGITIS.  4f)l 

croid.  Where  largo  glunds  lie  out  in  the  ulcer  and  have  not  suppu- 
rated, or  if  all  the  suppuration  have  come  from  periadenitis,  in  cases 
where  the  bubo  was  strumous,  these  glands  should  be  removed.  This 
is  best  done  with  the  finger,  tearing  them  away,  or  they  may  be  tied 
off  with  a  ligature.     Even  when  cut  away  they  rarely  bleed  much. 

Burrowing  and  phagedena  in  the  groin  are  treated  in  the  same 
manner  as  when  occurring  with  chancroid.  The  pastes,  carbo-sul- 
phuric  and  Vienna,  are  well  suited  to  phagedena  in  this  region. 
Where  suppuration  has  been  stayed,  and  in  all  cases  of  chronic  bubo 
in  which  strumous  degeneration  of  the  gland  plays  a  large  part,  reso- 
lution may  be  hastened  by  counter-irritants  and  pressure.  The  latter 
is  conveniently  applied,  the  patient  being  on  his  back,  by  placing  a 
bag  of  sand  or  fine  shot  over  the  swollen  glands,  or  by  a  spica  band- 
age over  compressed  sponge  laid  upon  the  swelling,  the  bandage  after- 
ward being  slightly  moistened.  Trusses  are  too  irritating,  but  it  has 
been  noticed  that  persons  wearing  trusses  and  afterward  getting  chan- 
croid rarely  have  bubo  uj)on  the  side  of  the  hernia,  probably  from 
previous  atrophy  of  the  gland  through  prolonged  pressure  (Eicord). 
If  there  has  been  periadenitis  wth  one  or  more  fistulse,  or  in  any  case 
of  protracted  trouble,  it  becomes  a  question  for  surgical  judgment 
whether  it  is  not  better  to  terminate  the  matter  at  once  by  free  incis- 
ions and  scraping  out  all  diseased  tissue  with  the  surgical  spoon. 
Such  a  course  is  always  successful,  and,  if  antiseptic  dressings  are  used, 
three  weeks  are  usually  enough  for  a  cure  even  in  very  severe  cases,  or 
enough  of  a  cure  to  let  the  patient  get  up  and  about. 

If  the  symptoms  never  become  sufficiently  severe  to  justify  sur- 
gical interference,  among  the  counter-irritants  repeated  punctate  cau- 
terization with  a  Paquelin  cautery  or  mild  repeated  blistering  are 
perhaps  best.  Tincture  of  iodine, has  positive  resolving  power  in  this 
stage.  Jacubowitz*  claims  success  from  interstitial  injections  of 
iodide  of  potassium. 

Internal  remedies  for  chronic  and  phagedenic  bubo  are  the  same  as 
for  similar  conditions  of  chancroid. 

(o)  Lymphakgitis,  or  inflammation  of  the  lymph-vessel,  never 
occurs  without  some  accompanying  inflammation  of  the  connective 
tissue  around  the  yessel,  perilymphangitis.  Its  varieties  are  identical 
with  those  of  bubo  ;  namely  : 

1.  Simple  inflammatory  lymphangitis,  which  may  be  found  in  con- 
nection with  any  inflammatory  abrasion,  simple,  chancroidal  (most 
common),  or  syphilitic  (least  common). 

2.  Virulent  lymphangitis,  only  found  in  connection  with  chan- 
croid. 

3.  Syphilitic  lymphangitis,  found  only  with  syphilis. 

The  first  two  varieties  are  indistinguishable  until  they  suppurate. 

*  "  Der  praktische  Arzt,"  xri,  No.  1. 


492  svrniLis. 

One  or  two  liard,  knotty  cords  arc  felt  under  the  skin  of  tlie  penis, 
usually  at  the  side.  They  commence  at  the  chancroid  (or  other 
lesion),  extend  for  a  greater  or  less  distance  up  the  penis,  sometimes 
up  to  the  glands  in  the  groin.  Occasionally  they  can  be  felt  only  to- 
ward the  root  of  the  i)enis.  The  integument  over  them,  in  mild  cases, 
is  unaltered  ;  in  severer  cases  their  course  is  marked  by  a  red  line. 
They  are  painful  to  the  touch,  and  during  erection.  The  penis  is 
often  red,  erysipelatous,  swollen,  edematous,  and,  in  severe  cases, 
there  are  fever,  sleeplessness,  etc. 

Lym2)hangitis  terminates  in  resolution  or  suppuration.  In  viru- 
lent lymphangitis  the  latter  is  inevitable.  In  the  simple  form  suppu- 
ration may  occur  in  one  or  more  spots,  resulting  in  abscesses,  which 
discharge  and  get  well.  In  virulent  lymi)hangitis  similar  abscesses 
form  along  the  line  of  the  vessel,  open,  furnish  auto-inoculable  pus, 
and  remain  as  chancroidal  ulcerations. 

Either  form  may  exist  without  bubo,  with  sim])lc  bubo,  or  with 
virulent  bubo.  The  affection  is  not  common,  and  bubo  is  most  fre- 
quently encountered  without  it. 

Treatment. — Rest,  cooling  lead-water  or  spirit  lotions,  collodion 
for  excessive  oedema,  perhaps  puncture,  poultice  for  severe  pain,  and 
oi)ening  abscesses,  when  they  form,  comj^rise  the  treatment.  Simple 
abscesses  are  best  treated  with  water-dressings  ;  virulent  abscesses  ex- 
actly like  chancroids,  which  indeed  they  are.  Internal  treatment  has 
no  influence  over  lymphangitis. 


CHAPTEK  III. 

STPHILIS. 

Nature.— Fnity  and  Duality.— Length  of  Time  required  for  Absorption  of  Virus.— Analogy  with 
Vaccine  Virus.— Second  Attacks  of  True  Sypliilis.— Transmissibility  to  Animals.— Incubation 
of  Syphilitic  Chancre.— Induration,  parchment-like,  split-pea,  diffuse.— Ulceration.— Secretion. — 
Pain.— Nature  of  Scar.— Auto-  and  Ilelero-Inoculation.— Vaccinal  Syphilis.— Multiple  Inocula- 
tion.—Fluids  capable  of  transmitting  Syphilis  by  Inoculation.— Methods  of  Transmission  of 
Syphilis.— Duration  of  Chancre.— Number.— Size.— Situation.— Form.-Symptoms  of  Urethral 
Chancre.  — Course  of  Chancre. —  Complications.  —  "Mi.xed  Chancre."  — Transformation  into 
Mucous  Patch.  —  Phagedena  and  Gangrene.  —  Treatment  of  Chancre. —  Syphilitic  Bubo. — 
Lymphitis. 

Syphilis  is  a  general  dyscrasial  blood-disease  caused  by  the  absorp- 
tion of  a  peculiar  virus  into  the  circulation,  manifesting  itself  primarily 
by  the  appearance  of  a  poisonous  sore  at  the  point  where  the  virus  en- 
tered, and  afterward  by  a  succession  of  morbid  manifestations  occur- 
ring at  longer  or  shorter  intervals — manifestations  which,  in  their 
totality,  interest  every  organ  and  tissue  in  the  body. 

The  virus  is  only  known  by  its  effects.     Exactly  what  it  is  has  not 


ANTAGONISM   OF  SYPHILIS  AND   CANCER.  493 

yet  been  determined  cither  by  the  microscopist  or  chemist.  Different 
observers  are  constantly  pointing  out  various  vegetable  organisms 
found  in  syphilitic  persons  in  the  blood  or  in  the  pathological  lesions, 
which  are  different  from  ordinary  forms  and  behave  differently  under 
staining,  but  so  far  every  observer  seems  to  find  the  alleged  morbid 
contagium  vivum  in  the  tertiary  as  well  as  the  other  lesions.  Whether 
Birch-Hirschfeld's  micrococci  or  Lustgarten's  (the  last  and  most  gen- 
erally accepted)  *  will  survive  the  critical  investigation  of  scientists 
longer  than  Klebs's  helikomonads  or  Lostorfer's  corpuscle  remains  to 
be  seen.  In  any  case  it  can  not  be  now  asserted  that  a  living  conta- 
gious element  of  syphilis  exists,  although  it  is  more  than  probable  that 
such  is  the  case,  and  that  it  will  be  one  day  triumphantly  demon- 
strated. 

Diday,  EoUet,  and  Eodet  failed  to  inoculate  syphilis  upon  cancer- 
ons  patients,  and  assume  an  antagonism  between  the  two  maladies. 
This  surely  does  not  exist.  I  have  seen  many  of  the  varieties  of  can- 
cer upon  syphilitic  patients.  Hutchinson,  f  at  the  forty-sixth  meet- 
ing of  the  British  Medical  Association,  recorded  his  belief  that,  while 
the  syphilitic  dyscrasia  was  not  a  cause  of  cancer,  yet  the  local  irrita- 
tion of  syphilitic  sores  might  call  out  local  cancerous  degeneration. 
I  have  seen  such  local  epithelial  degeneration  of  old  syphilitic  patches, 
and  I  have  of  eczematous,  lupoid,  warty,  and  other  pathological  condi- 
tions of  the  integument  as  well. 

Syphilis  has  been  happily  compared  by  Hutchinson  to  the  conta- 
gious exanthemata,  small-j)ox,  measles,  scarlet  fever,  as  possessing  all 
the  peculiar  characters  common  to  this  group  of  diseases,  namely  :  it  is 
communicated  only  from  one  diseased  person  to  another  healthy  one  ; 
it  has  a  stage  of  incubation  before  any  sign  of  the  disease  appears ; 
it  has  a  stage  of  efflorescence,  which  indeed  in  syphilis  is  prolonged 
and  marked  by  relapses  ;  it  has  a  period  of  decline  and  sequelse — the 
later  tertiary  lesions — which  do  not  always  occur,  and  during  which 
the  disease  often  ceases  to  be  communicable.  Again,  most  of  the  vari- 
ous ef&orescences  of  syphilis,  like  those  of  the  other  exanthemata,  tend 
to  pass  away  spontaneously  after  a  time  ;  thus,  as  Fournier  aptly  puts 
it,  affording  a  triumph  to  every  method  of  treatment.  One  attack 
confers  immunity  from  another  often  for  life,  always  for  a  long  period. 
The  disease  is  transmissible  by  inheritance,  as  in  the  case  of  the  other 
exanthemata  when  the  child  is  born  before  the  mother  recovers  from 
disease.  Finally  the  sequelae  do  not  constitute  transmissible  disease 
even  by  inheritance.  As  in  the  other  zymotic  diseases,  a  portion  of 
the  virus,  however  small,  is  capable  of  infecting  the  whole  body,  as  if 
by  fermentation.     Thus  the  analogy  of  syphilis  with  the  contagious 

*  "  Med.  Jahrbiicher."     Herausgegeben  von  der  K.  K.  Gesellschaft  der  Xrzte,  1SS5, 
p.  89. 

f  "  British  Medical  Journal,"  August  24,  1878,  p.  282. 


494  SYruiLis. 

exanthemata  is  clear,  only  its  febrile  symjitoms  are  less  marked,  its 
elliorescenees  more  varied,  and  its  course  much  more  protracted — 
counted  by  mouths  instead  of  days — and  more  subject  to  variation  as 
well  as  more  amenable  to  treatment.  Syphilis  is  fortunately  only 
contagious,  it  is  not  infectious  ;  its  poison  is  not  volatile,  is  not  dif- 
fused in  the  air ;  direct  contact  of  tlie  virus  with  a  surface  capable  of 
absorption  is  essential  to  the  production  of  the  disease. 

The  arguments  and  theories  concerning  the  utility  or  duality  of 
the  syphilitic  virus  are  out  of  place  in  a  text-book.  "What  syi)hilis  is 
will  be  shown  in  the  following  pages  ;  what  it  is  not,  has  been  already 
set  forth.  In  the  early  part  of  this  century  measles  was  not  distin- 
guished from  scarlet  fever,  and  the  best  pathologists  set  down  chan- 
croid, gonorrhoea,  and  vegetations,  all  as  syphilitic.  But  truth  has 
appeared,  though  slowly,  and  at  tlie  present  day  the  great  majority  of 
the  most  reliable  authorities  on  syphilis  are  in  accord.  Old  Avriters 
are  dangerous  guides,  for  they  had  no  aid  from  the  light  of  experi- 
mentation furnished  to  the  jiresent  generation  by  Eicord,  Bassereau, 
Clerc,  and  a  host  of  others.  Few  at  the  present  day  can  be  found  who 
could  fall  into  the  error  of  Hunter,  and  consider  as  gonorrhoea  a  ure- 
thral discharge  producing  syphilitic  chancre  by  hetero-inocnlation, 
since  urethral  chancre  is  so  well  known  ;  but  many  still  look  upon 
vegetations  as  indicating  syphilis,  and  there  are  some  distinguished 
names  still  laboring  to  preserve  the  identity  of  chancroid  with  sj'philis, 
and  that,  mainly,  because  exceptional  examples  or  obscure  cases,  not 
thoroughly  well  marked,  seem  sometimes  to  give  the  symptoms  of 
syphilis  after  an  apparent  chancroid,  and  no  syjihilis  after  a  seeming 
chancre.  Kollet  *  has  ably  dealt  with  these  cases,  about  which  some- 
thing will  be  said  farther  on  ;  suffice  it  now  to  remark  that  the  fight 
is  based  upon  exceptions.  In  the  vast  majority  of  reasonably  well- 
marked  cases,  syphilis  is  as  different  from  chancroid  as  night  from 
day.  A  patient  may  have  malignant  scarlet  fever  and  die  in  a  day 
without  a  sign  of  eruption,  but  still  he  has  scarlet  fever,  as  no  one 
denies.  Even  if  one  syphilitic  chancre  out  of  twenty  were  not  indu- 
rated, the  other  nineteen  would  be  amjoly  sufficient  to  establish  a  rule. 
But  the  proportion  is  far  larger,  and  there  is,  perhaps,  no  symptom  of 
any  disease  more  constant  than  is  the  induration  of  syphilitic  chancre, 
yet  the  patient  does  not  have  syphilis  because  his  chancre  indurates — 
as  was  formerly  taught — on  the  contrary,  he  already  has  syphilis  be- 
fore his  chancre  appears.  If  he  did  not  have  it,  he  could  have  no 
chancre  at  all,  and  the  induration  of  that  chancre  is  just  as  much  one 
of  its  symptoms  as  is  ulceration  of  a  chancroid.  If  a  patient  is  ex- 
posed to  measles,  and  dies  during  the  period  of  incubation,  before  he 
is  at  all  sick,  he  can  not  be  said  not  to  have  the  measles  ;  the  same  of 
a  patient  who  has  absorbed  syphilitic  virus  :  he  has  syphilis  at  once, 

*  "Traitd  des  Maladies  v6n6riennes,"  Paris,  1866. 


ABSORPTION   OF   VIRUS.  495 

and  because  he  has  syphilis  lie  gets  a  sore  at  the  point  of  entrance  of 
the  poison,  after  a  period  of  incubation,  as  the  first  symptom  of  the 
disease.  This  chancre  may  be  destroyed  by  caustic,  or  the  knife,  but 
the  disease  will  run  its  course  unaltered. 

Interval  befoke  Absouption. — Clcrc  *  tells  of  a  medical  student 
who  washed  himself  immediately  after  sexual  intercourse,  and  on  care- 
ful examination  for  several  days  subsequently  detected  absolutely 
nothing ;  twenty-eight  days  afterward  chancre  appeared,  followed  by 
general  syphilis. 

Hillf  relates  a  very  important  case  bearing  upon  this  point.  A 
man  in  sexual  intercourse  tore  his  frasnum  at  4  a.  m.  The  wound 
bled  freely.  Fearing  possible  infection,  he  called  upon  Hill  during 
the  same  day,  within  twelve  hours  after  the  accident.  To  quiet  his 
fears,  although  there  was  no  lesion  evident  except  the  abrasion.  Hill  cau- 
terized the  surface  freely  at  once  with  fuming  nitric  acid.  The  slough 
separated  in  due  time,  leaving  a  healthy  surface,  which  cicatrized 
promptly.  About  one  month  afterward  the  scar  indurated.  It  never 
ulcerated  again,  but  the  regular  manifestations  of  true  syphilis  came 
on  at  the  usual  interval. 

What  more  striking  evidence  could  there  be  of  the  inability  of  any 
local  cauterization  to  interfere  with  the  regular  development  of  this 
blood-disease,  after  it  has  once  been  acquired  ? 

Diday  J  cauterized  a  syphilitic  chancre  within  six  hours  after  its 
appearance  ;  but,  although  the  sore  healed  promptly,  general  syphilis 
followed. 

No  attempts  have  been  made  experimentally  to  destroy  the  point 
where  true  syphilis  has  been  inoculated  upon  healthy  subjects,  but  the 
experience  furnished  by  the  known  action  of  other  poisons  may  be  used 
to  form  a  conclusion  by  analogy.  The  rapidity  of  absorption  of  the 
poison  of  a  snake-bite  is  well  known,  as  is  also  that  of  rabies  and  the 
poison  of  a  dissecting  wound,  and  there  is  no  reason  why  that  of  syphi- 
lis should  be  less  so.  The  French  veterinary  surgeons  have  inoculated 
horses  with  the  poison  of  glanders,  cutting  out  the  seat  of  inoculation 
one  minute  after  insertion,  but  the  disease  followed  just  as  surely  as 
if  nothing  had  been  done.  Similar  experiments  have  been  performed 
on  sheep  with  the  same  result.  Clerc*  vaccinated  some  children, 
destroying  the  inoculated  point  one  hour  afterward  with  nitrate  of 
silver ;  vaccinia  followed,  and  a  second  vaccination  failed  to  take. 
Seven  children  were  vaccinated  by  Aime  Martin,  ||  and  the  spot  de- 
stroyed with  Vienna  paste  at  intervals  varying  from  one  to  twenty- 
four  hours  after  insertion  of  the  virus,  Xone  of  the  children  had 
vaccinia,  but  that  the  vaccination  was  protective  is  i^roved  by  the  fact 

*  "Traite  pratique  des  Maladies  veneriennes,"  Paris,  1866. 

f  "  On  Venereal  Diseases,"  London,  1S6S.  *  Quoted  by  Hill. 

t  "  Annuaire  de  la  Syphilis,"  1S58.  |  "  These  de  Paris,"  1863. 


496  SYPHILIS. 

that  in  only  one  out  of  the  seven  cases  could  vaccinia  be  produced  by 
subsequent  insertion  of  vaccine  lymph  under  the  skin. 

Tiiis  analogy  seems  perfect.  The  spot,  even  during  the  period  of 
incubation,  may  be  destroyed  so  thoroughly  that  no  evidence  of  the 
entrance  of"  the  poison  will  be  manifested  by  a  subsequent  character- 
istic sore  ;  yet  that  the  protective  power  of  the  poison  (vaccine  virus) 
operates  as  well  as  if  the  characteristic  sore  had  appeared  is  shown  by 
the  failure  of  subsequent  attempts  at  vaccination. 

Second  Attack  of  Thte  Syphilis. —  Hutchinson*  saw  a  well- 
marked  case,  in  a  physician,  of  two  attacks  of  syphilis,  each  preceded 
by  its  characteristic  syphilitic  chancre.  The  same  patient  had  had 
small-pox  twice.  Many  other  cases  are  found  scattered  through  the 
literature  of  syi)hilis,  and  they  go  to  prove  that  syphilis  gets  well,  for, 
until  one  attack  is  recovered  from,  another  can  not  be  acquired. 
Diday  f  has  collected  twenty-five  cases,  of  which  he  personally  saw 
twenty.  All  had  had  syphilitic  symptoms,  which  had  disappeared, 
except  in  a  few,  where  some  late  (tertiary)  symptoms  remained.  In 
all  of  these  cases  there  was  syphilitic  chancre  with  cliaracteristic  in- 
duration, occurring  a  second  time  after  a  previous  syphilis.  In  four- 
teen the  inguinal  glands  were  not  indurated,  and  there  was  no  further 
sign  of  syphilis.  In  nine,  general  syphilitic  symptoms  ajipearcd,  but 
they  were  less  intense  than  during  the  first  attack.  In  two  the  second 
attack  was  more  severe  than  the  first. 

In  analyzing  these  cases,  Diday  found  that  in  none  did  the  second 
chancre  appear  until  all  signs  of  previous  syphilis  had  passed  away, 
or,  in  some  cases,  where  tertiary  (non-transmissible  sequelce)  symptoms 
alone  remained.  The  nearer  the  second  attack  came  to  the  first  the 
more  feeble  was  the  effect  of  (second)  infection,  yielding  only  chancre  ; 
the  gi'eater  the  interval  the  more  marked  the  effect.  The  two  severe 
cases  followed  their  in-edecessors  after  more  than  nineteen  years.  The 
lighter  attacks  followed  severe  ones,  and  vice  versa.  Dida}-  concludes 
that  the  minimum  time  for  the  cure  of  syishilis  is  twenty-two  months, 
and  that,  where  syi)hilitic  chancre  appears  twice  in  the  lifetime  of  an 
individual,  the  second  attack  should  not  be  treated  until  symptoms  of 
secondary  syphilis  appear,  as  these  may  never  come  on,  the  whole 
attack  consisting  simply  in  syphilitic  chancre. 

Heinrich  Koebner  J  has  recently  again  collated  the  evidence  on  this 
subject.  He  has  collected  into  a  table  over  forty  cases  of  supposed 
reinfection ;  but  that  these  cases  of  syjihilis,  reoccurring  in  an  indi- 
vidual, are  still  very  exceptional,  and  not  as  common  even  as  we  might 

*  Loc.  cii. 

■f-  "  De  la  Reinfection  syphilitique,  de  se3  Degr6s  ct  de  ses  Modes  divers,"  "  Archives 
G6nerales  de  Medcciue,"  July  and  August,  1863. 

X  "  Berliner  klinische  Wochenschrift,''  46,  p.  549,  72.  "  Ueber  Keinfection  mit  consti- 
tutioneller  Syphilis." 


SECOND   ATTACK   OF  TRUE   SITBILIS.  407 

be  led  to  suppose  from  finding  mention  of  nearly  half  a  hundred  in 
the  same  essay,  is  shown  by  a  careful  perusal  of  the  article  in  question. 
Several  of  the  cases  detailed  by  Koebner  were  certainly  tertiary  ulcera- 
tions of  the  penis,  mistaken  for  syphilitic  chancre,  as  indeed  Sigmund 
has  already  pointed  out  in  regard  to  some  of  these  very  cases,*  and 
Case  VIII,  on  which  Koebner  lays  most  stress,  is,  of  all,  most  clearly 
one  of  tertiary  ulceration.  The  facts  of  this  case  are  briefly  these  :  A 
man  of  forty-five  has  S3'philis  in  18GG,  and  his  wife  an  ulcerated  tuber- 
cular syphilide  in  1867.  In  1871  the  man  ai^plied  for  treatment  of  a 
very  hard,  flat  ulcer,  quite  large,  and  with  sharp-cut  edges,  saying 
that  it  had  ulcerated  within  the  previous  twenty-four  hours.  Inguinal 
glands  intact.  His  last  periods  of  sexual  intercourse  were  ten  weeks 
previously  with  a  prostitute  ;  nine  and  nineteen  days  before  date,  with 
his  wife.  The  wife  was  examined,  found  healthy,  and  remained  so  ; 
the  patient  still  bore  evidences  of  tertiary  syphilis  upon  his  person. 
His  ulcer  on  the  penis  got  well  under  iodide  of  potassium,  and  he  had 
no  eruption  or  other  evidence  of  syphilis  after  it.  Such  a  case  requires 
no  comment. 

Since  the  foregoing  remarks  were  written,  a  considerable  number 
of  new  isolated  cases  have  appeared,  vouched  for  by  competent  writers, 
Gascoyne,  Oaspary,f  Taylor, J  Thebaud,  Lemaire,  Venot,  Malherbe, 
and  many  others,  and  a  few  articles  have  come  out  on  the  subject  cov- 
ering the  same  ground.  I  find,  however,  nothing  new,  nothing  to 
disprove  the  general  statement  that,  while  second  attacks  of  true 
syphilis  are  possible,  they  are  very  exceptionally  rare,  much  more  in- 
frequent than  the  literature  of  the  subject  would  lead  one  to  suppose, 
and  that  the  highest  position  of  the  observer  does  not  shield  him  from 
the  possibility  of  making  a  mistake  upon  a  subject  so  surrounded  with 
difficulties  of  accurate  observation  as  this  one. 

Hutchinson  *  records  a  case  in  which  a  woman  with  mild  inherited 
syphilis  got  a  new  attack  in  the  usual  way  at  the  age  of  twenty.  Mer- 
kel  II  has  a  similar  case  even  more  strongly  marked. 

Personally,  although  I  have  several  times  treated  patients  who  had. 
been  through  long  courses  of  mercurial  treatment  for  alleged  syphilis, 
and  came  to  me  with  true  syphilitic  chancre,  and  have  seen  other  cases 
of  alleged  chancre  in  patients  whom  I  had  known  to  be  formerly 
syphilitic,  yet  I  have  been  always  able  to  unravel  the  points  of  diffi- 
culty to  my  own  satisfaction,  and  I  can  honestly  state  that  I  have 
never  seen  a  case  of  syphilitic  reinfection  to  recognize  it. 

While,  then,  a  second  true  syphilitic  infection  is  possible  even  while 

*  Pitha  und  Billroth,  "  Eandbuch." 

f  Quoted,  "  Med.  Times  and  Gaz.,"  Dec.  5,  1874. 
X  "  Vierteljahrschrift  f.  Derm.  u.  Syph.,"  1,  1876. 

*  "  London  Hospital  Reports,"  vol.  ii,  p.  164,  1865. 
II  Quoted  by  Koebner,  loc.  cit. 

32 


498  SYrniLis. 

the  subject  bears  the  marks  of  late  tertiary  disease,  yet  sucli  infection 
is  eminently  exceptional,  and  allowance  must  be  made  in  the  reported 
cases  for  (1)  chancroid  accomjxmied  by  some  eruption,  as  a  coincidence  ; 
{2)  ecthyma  mistaken  for  syphilis,  after  which  the  first  true  syphilitic 
infection  might  pass  for  a  second  ;  (3)  false  chancre,  indurated  mucous 
patch  ;  and  (4)  cases  of  tertiary  ulcer  faultily  diagnosticated. 

Tkaxsmissibility  to  Animals. — Besides  this  peculiarity  of  only 
appearing  once  in  a  given  individual,  syphilis  differs  from  chancroid  in 
not  being  transmissible  to  animals.  Lanccrcaux,  quoting  Ruiz  Diaz 
de  Isla,  mentions  fancifully  thai  even  plants  have  been  accused  of  hav- 
ing syphilis  transmitted  to  tiiem  by  sprinkling  them  with  water  which 
had  been  nsed  to  wash  syphilitic  ulcers.  Horses  and  asses  suffer  some- 
times from  a  disease,  the  "doury,"  jjerhaps  remotely  analogous  to 
syphilis,  which  is  transmitted  only  by  sexual  intercourse.  It  comes 
on,  after  an  incubation  of  four  to  six  weeks,  with  fever  and  cutaneous 
tumors  (not  the  subcutaneous  tumors  of  farcy).  The  mucous  mem- 
branes, glands,  eyes,  and  bones,  take  part  in  the  disease.  Atrophies 
and  paralyses  follow.  It  lasts  from  two  months  to  three  years,  and  is 
not  transmissible  by  inoculation.  These  animals  also  have  a  local  con- 
tagious, venereal  affection  (Lancereaux).  Cows  are  said  to  have  some- 
what similar  affections,  but  it  has  been  found  impossible  or  very  diffi- 
cult to  propagate  any  of  these  maladies  by  inoculation,  and  their  com- 
parison with  syphilis  is  at  best  fanciful. 

Paul  Topinard  *  mentions  an  ape  which  was  the  subject  of  a  com- 
munication to  the  Anthropological  Society  in  London,  18G5,  who  had 
ulceration  of  the  generative  organs  followed  by  loss  of  hair  and  an 
affection  of  the  bones. 

Since  the  earlier  experiments  (abortive  ones)  of  Auzias  Turenne,  f 
the  alleged  syphilitic  monkey  of  Depaul  and  the  cat  of  Vernois,  Lan- 
cereaux's  guinea-pig,  J  Bradley's  *  guinea-jiig  and  kitten,  Legros's 
guinea-pig,  Horaud  and  Pencil's  |  dogs,  horses,  cows,  and  other  animals, 
in  some  of  which  cases  ulcers  of  mucous  membranes,  local  cutaneous 
lesions,  lymphatic  glandular  swelling,  loss  of  hair,  and  internal  gum- 
mata  with  bone  lesions  are  reported  to  have  been  found,  we  have  the 
more  recent  experiments  in  the  same  direction  of  Klebs,"^  who  by  in- 
oculating an  ape  with  a  bit  of  hard  chancre  thought  he  produced 
syphilitic  symptoms  ;  of  Hausell,  ()  who  believes  that  he  has  been  able 
to  inoculate  rabbits  with  syi^hilis  ;  of  Eabatel,  J  who  failed  to  gain  any 

*  "  Anthropoloiry,"  translated  hy  R.  T.  II  Bartlcy,  London,  IS'ZS,  p.  160. 
f  "  Bull,  do  I'Acad.  de  Med.,"  1844,  I,  10,  p.  212. 

i  "Traill^  de  la  Syphili.s,"  2d  edition,  1873,  p.  596. 

*  "  Brit.  Med.  Journal,"  September  30,  1871,  p.  376. 
II  "  Annale.s  de  Derm,  et  de  Syph.,"  I,  iv,  p.  387. 

^  "All.  Wicn.  mod.  Zeitung,"  October  15,  1878,  p.  418. 

0  "  Archiv  f.  Ophthalmologic,"  Berlin,  1881,  No.  3,  p.  93. 

J  "  Rccherchcs  experimentales,"  etc.,  "  Lyon  Med.,"  January  8,  1882. 


INCUBATION  OF  SYPHILIS.  4(j9 

success  upon  any  animal  by  inoculating  gonorrhcBa,  chancroid  or  the 
tissue  of  indurated  chancre  ;  of  Martincau,  *  who  excised  a  chancre, 
cultivated  it  appropriately  in  a  flask,  injected  some  of  the  liquid  into 
the  peritoneal  cavity  of  a  pig,  and  in  a  month  got  some  pimples  on  the 
abdomen,  a  conjunctivitis,  a  tumor  on  the  penis,  while  another  pig  in- 
oculated from  a  hard  chancre  had  similar  symptoms ;  of  Martincau 
again,  f  who  inoculated  a  monkey  with  syphilis,  got  chancre  in  twenty- 
eight  days,  then  had  papulo-erosive  and  diphtheroid  lesions  on  the  penis, 
glands,  in  the  groin  and  axilla,  and  under  the  jaw,  loss  of  flesh,  alopecia 
of  head  and  back,  and  ten  months  after  infection  ulceration  in  the  vault 
of  the  palate.  Finally,  Cognard  I  inoculated  a  monkey  from  a  cul- 
tivation liquid  prepared  by  Chauveau  from  the  pus  of  a  syphilitic 
sore.  The  animal  got  lesions  in  his  mouth  and  on  his  soles  resembling 
those  of  secondary  syphilis  5-  another  monkey  had  some  obscure  lesions 
from  inoculation.  Finally,  J.  Neumann  *  inoculated  three  aj)es,  three 
rabbits,  a  horse,  a  hare,  a  white  rat,  a  marten,  a  cat — total  of  inocula- 
tions, fifty-four — and  absolutely  failed  in  every  instance. 

What  then  shall  be  said.  Only  this  :  The  symptoms  in  animals  who 
are  alleged  to  have  been  successfully  inoculated  with  syphilis  are  ir- 
regular, obscure,  indefinite.  They  suggest  but  do  not  assert  syphilitic 
contamination,  and  many  experiments  yield  very  doubtful  or  negative 
results.  It  can  not  therefore  be  yet  asserted  that  the  syphilitic  dis- 
ease is  transmissible  to  animals.  The  demonstration  of  the  possibility 
of  infecting  lower  animals  with  chancroid  is  much  more  positive.  So 
far  as  experimental  demonstration  yet  goes,  it  must  be  asserted  that 
the  sad  privilege  of  having  true  syphilis  belongs  only  to  man. 

iNCUBATioisr  OF  SYPHILIS. — After  the  poison  of  syphilis  has  been 
absorbed,  the  break  in  the  epithelium  through  which  it  entered  heals, 
and  the  virus  ferments,  as  it  were,  in  the  blood,  until  it  is  ready  to  give 
itself  local  expression,  first  at  the  point  of  entrance  in  the  form  of 
syphilitic  chancre.  Such  an  abraded  point  may  be  kejot  open  by  dirt  or 
by  suppurating  and  ulcerating  from  the  start  if  the  syphilitic  poison 
comes  from  a  much-inflamed  irritated  chancre,  and  particularly  so  if 
the  yirus  of  a  chancroid  be  inoculated  at  the  same  time  upon  the  same 
spot  (mixed  chancre).  In  such  case  either  there  is  no  spot  to  mark 
the  entrance  of  the  poison  for  many  days,  or  a  simple  temporary  fester 
appears  to  get  well  shortly,  the  actual  syphilitic  lesion  not  developing 
until  after  a  time,  or  the  sore  may  run  its  course  as  a  chancroid  later, 
becoming  indurated  and  putting  on  syphilitic  characters. 

This  period  of  incubation,  or  hatching,  has  been  critically  studied 
by  many  authors,  both  by  inoculation  upon  healthy  subjects  and, 

*  Editorially,  "Lancet,"  September  16,  1SS2,  p.  45'7. 
f  "  Lyon  Med.,"  December  28,  lSS-3. 

i  Editorially,  "Lancet,"  June  14,  ISSi,  p.  1090. 

*  "  Wien.  med.  "Wochenschrift,"  February  21,  1SS3. 


500  SYPniLis. 

clinically,  by  close  observation  of  pntients.  The  results  arrived  at 
are  in  the  main  identical.  The  usual  period  after  contact,  or  inocu- 
lation, at  which  a  chancre  first  appears  is  about  the  end  of  the  third 
week.  It  is  not  unusually  at  four,  and  may  in  exceptional  cases  be 
much  later,  reaching  ten  weeks.  Many  authentic  cases  of  longer  in- 
cubation are  on  record.  Aim^  Martin  *  cites  a  girl  whose  chancre^ 
appeared  seventy-two  days  after  being  shut  up  in  jirison.  Fouruier  ^ 
has  one  as  long,  and  speaks  of  another  under  the  care  of  Guerin,  and 
Fox,  I  of  New  York,  has  one  of  seventy-five  days.  The  possibility  of 
error  in  these  few  cases  must  not  be  lost  sight  of.  The  longest  period 
of  incubation  that  I  can  find  among  the  authentic  cases  of  experimental 
inoculation  is  forty-six  days  ;  the  inoculation  was  made  from  an  in- 
durated chancre  by  Daniclssen.*" 

There  are  some  apparent  exceptions  on  the  short  as  well  as  the  long 
side  of  the  incubative  period.  Hammond  ||  has  a  case  of  thirty-six 
hours,  Taylor-^  one  of  twenty-four  hours,  at  which  time  a  silvery  spot 
appeared.  Hill  and  Cooper^  cite  two  surgeons,  whose  digital  lesions 
showed  about  ten  days  after  contact  with  infected  secretions,  and  Rollct  J 
has  an  ordinary  case  of  the  usual  kind,  in  which  he  believes  the  incuba- 
tion to  have  been  nine  days.  There  is,  then,  no  case  on  record  of  an 
incubation  less  than  nine  days,  except  the  cases  of  Taylor  and  Ham- 
mond. The  latter  is  not  a  skilled  observer  in  syi^hilitic  matters  :  in  the 
former  the  lesion  was  a  peculiar  one,  and  I  can  do  nothing  better  than 
record  it  as  an  unexplained  exceijtion.  The  shortest  period  of  in- 
cubation in  a  case  of  experimental  inoculation  was  Lindmann,:|;  who 
inoculated  himself  from  an  ulcer  on  the  tonsil  of  a  friend.  During 
the  period  of  incubation  the  patient  bears  no  sign  of  disease,  and  the 
habitual  clinical  limits  are  as  clearly  traced  as  any  other  symptom  of 
the  disease.  During  the  fourth  week  after  exposure  a  syphilitic  chan- 
cre appears. 

This  is,  perhaps,  the  most  valuable  mark  of  a  syphilitic  chancre, 
and  practically  all  sores  appearing  later  than  ten  days  after  suspicious 
contact  must  be  regarded  with  distrust,  while  those  coming  sooner 
may  be  more  lightly  considered. 

Induration  of  Syphilitic  Chancre. — The  period  of  incubation 
of  a  chancre  can  not,  clinically,  be  always  oljtained  with  accuracy. 
Induration  can  always  be  felt  when  present,  and  in  well-marked  cases 

*  "Th(ise  de  Paris,"  1863,  p.  28. 

f  "  Syphilis  chczla  Femme,"  1873,  p.  16. 

X  "Archives  of  Dermatology,"  1879,  No.  3,  p.  267. 

*  "Deutsche  Klinik,"  1858,  p.  322. 
II  "  On  Venereal,"  1864,  p.  26. 

^  "  Am.  Jour,  of  Syph.  and  Derm.,"  1871,  p.  244. 

^  "Syphilis  and  Local  Contatrious  Disorders,"  second  edition,  1881,  p.  81. 

^  "  Pluralit6  des  Maladies  veneriennes,"  p.  26. 

$  "  Bull,  de  I'Acad.  de  Med.,"  July  20,  1852. 


INDURATION   OF  CHANCRE.  501 

it  is  absolutely  pathognomonic.  It  consists  in  an  infiltration  of  the 
tissues  underlying  the  chancre  with  small  round  or  oval  and  spindle 
cells,  some  granular  matter  and  free  nuclei,  and  thickening  of  the 
coats  of  the  vessels.  It  may  only  partially  underlie  tljc  ulceration  in 
exceptional  cases.     It  exists  in  three  varieties  : 

1.  A  thin  superficial  layer  of  induration,  aptly  called  '^'parchment- 
like,"  exactly  underlying  the  ulceration.  This  may  escaiw  notice,  un- 
less the  sore  be  pinched  up  carefully  with  the  thumb  and  finger, 
placed  on  either  side,  and  lightly  pressed  upon,  so  as  not  to  be  bent  or 
folded  by  the  pressure.     This  is  the  commonest  form. 

2.  The  induration  may  resemble  a  split  pea,  situated  exactly  be- 
neath the  ulcer,  which  is  upon  its  flat  surface.  This  induration  is 
easily  felt  and  is  unmistakable  when  present.  It  is  little  or  not  at  all 
sensitive,  freely  movable  over  the  jiarts  beneath,  hard  like  bone  or 
wood,  or  like  cartilage,  having  indeed  a  certain  springy,  elastic  feel. 
It  is  sharply  defined,  clean  cut  as  it  were,  ends  abruptly,  and  does 
not  shade  off  into  the  surrounding  tissues,  like  inflammatory  indura- 
tion. 

3.  The  induration  may  be  very  extensive,  far  surpassing  the  bounds 
of  the  ulceration  placed  upon  it,  excavated  or  convex  upon  its  surface  ; 
but  here  all  the  characters  and  qualities  of  the  induration  are  the  same 
as  those  detailed  above  for  the  split-pea  variety,  only  there  is  more  of 
it.  The  skin  over  it  is  not  usually  red,  and  the  feel  is  far  different 
from  the  boggy,  inelastic  sensation  given  to  the  fingers  by  pressure  on 
an  inflammatory  induration. 

Induration  is  greater  or  less,  according  to  the  tissue  in  which  it  is 
formed.  It  is  usually  greatest  in  chancres  of  the  skin,  lips,  nipples, 
behind  the  corona  glandis,  and  near  the  fraenum  of  the  penis.  In 
spongy  tissues  like  the  glans  penis,  the  induration  is  often  very  slight. 
In  certain  very  rare  cases,  it  appears  to  be  altogether  absent,  probably 
sometimes  because  it  had  not  yet  appeared  at  the  moment  of  examina- 
tion, or  had  passed  away,  and  undoubtedly  sometimes  because  the 
true  syphilitic  lesion  was  not  detected,  but  some  chancroid,  existing 
simultaneously,  was  discovered,  found  soft,  and  believed  to  be  the  ori- 
gin of  the  syphilis  that  followed.  Again,  when  a  syphilitic  chancre 
becomes  phagedenic,  it  loses  its  induration  at  once. 

The  induration  of  a  syphilitic  chancre  may  precede  the  ulceration 
or  may  follow  it.  In  the  latter  case  it  comes  on  during  the  first  week. 
The  parchment-like  variety  disappears  the  soonest.  It  has  been  ob- 
served to  last  only  twelve  days  (Clerc).  Usually,  however,  any  form 
of  induration  will  outlast  the  ulceration — remaining,  indeed,  for  two 
or  three  months.  More  rarely  it  lasts  for  years,  as  a  cicatricial  hard- 
ness similar  in  feel  to  the  true  syphilitic  induration,  Eicord  records 
one  case  of  thirty  years'  standing.  Fading  induration  may  suddenly 
reappear,  and  increase  on  the  outcropping  of  general  symptoms.    Four- 


502  SYPHILIS. 

nier*  first  described  certain  indurations  which  occasionally  appear  in 
the  neighborhood  of  a  syphilitic  chancre,  though  not  immediately  con- 
nected with  it.  They  are  formed  in  and  around  the  lymphatic  vessels, 
and  niay,  very  rarely,  also  ulcerate. 

Ulceratiox  of  Syphilitic  Chaxcre. — Properly,  sj-philitic  chan- 
cre does  not  ulcerate.  It  consists,  in  more  than  half  the  cases,  simply  of 
an  excoriated  surface,  looking  red  and  bloody,  perhaps  pultaceous,  very 
superficial,  not  infrequently  scabbed  when  exposed  to  the  air.  In- 
deed, it  may  never  even  excoriate,  although  this  is  exceedingly  rare, 
the  lesion  consisting  in  a  simple  indurated  tubercle,  which  scales  oil'  a 
little  at  the  top,  but  from  which  the  epithelium  is  never  absent — in 
other  words,  which  is  never  even  moist.  Chancre,  however,  especially 
of  the  genitals,  rarely  escapes  more  or  less  inllammation,  hence  it  is 
the  rule  to  find  some  shallow,  occasionally  deep,  ulceration.  When 
shallow,  the  ulcer  is  round  or  oval,  with  slanting  borders,  often  a  red 
base,  sometimes  partly  covered  with  a  pultaceous  deposit.  When 
deep,  the  borders  are  never  abrujit,  as  in  chancroid,  but  always  sloped 
off.  The  cavity  is  funnel-shaped.  The  borders  of  the  ulcer  are  ad- 
herent all  around,  never  by  any  chance  undermined,  as  they  occasion- 
ally are  in  chancroid.  Sometimes  the  induration  left  behind  on  the 
healing  of  a  chancre  reulcerates. 

Character  of  the  Discharge. — Pus  does  not  form  as  such  on 
true  syphilitic  chancre,  unless  it  be  inflamed,  when  the  thickness  of 
the  pus  will  vary  with  the  degree  of  the  inflammation.  Ordinarily 
the  discharge  is  sero-purulent,  or  purely  serous  in  appearance,  often 
bloody,  and  sometimes,  on  the  dry,  indurated  papule^  there  is  abso- 
lutely no  discharge  at  all. 

Paix. — In  unirritated  syphilitic  chancre  as  a  rule  there  is  abso- 
lutely no  pain.  A  patient  often  carries  a  chancre  for  a  considerable 
time  without  susi^ecting  its  existence,  and  sometimes,  undoubtedly,  it 
comes  and  goes  without  being  discovered  at  all.  In  this  way  may  be 
explained  many  singular  cases  of  undoubted  syphilis,  apparently  not 
preceded  by  any  primary  lesion. 

Cicatrix. — The  scar  left  by  chancre  varies.  In  the  majority  of 
cases  where  there  is  only  a  slight  excoriation  or  exulceration,  no  scar 
whatever  is  left  behind.  In  other  cases  the  scar  is  proportionate  to  the 
depth  of  the  ulcer.  These  scars  are  occasionally  pigmented.  At  first 
they  are  discolored — of  a  dark,  vinous  hue,  like  the  ordinary  syphilitic 
tubercle,  of  a  color  aptly  compared  by  Fallopius  to  the  flesh  of  raw 
ham.  This  color  may  be  followed  by  tlie  true  copper-colored  (Swe- 
diaur)  or  bronzed  pigmentation.  The  latter  sometimes  approaches  a 
black.  It  clears  off  gradually  from  the  center,  to  leave  the  scar  finally 
whiter  than  the  surrounding  skin.  Induration  generally  vanishes,  but 
there  may  remain  a  cicatricial  hardness  about  the  scar  permanently. 

*  "]6tude  clinique  sur  I'lndiiration  syphilitiquc  primitive,"  "Arch.  Gen.,"  1858. 


AUTO-INOCULATIOJf.  503 

Inoculation. — Ilctoro-inoculatioti  of  sypliiliLic  virus  upon  healthy 
individuals  was  first  performed  by  Wallace  in  1835,  with  virus  derived 
from  mucous  patches.  It  has  since  been  very  tlioroughly  studied  by 
the  few  experimenters  who  have  practised  it,  aided  by  the  light  of 
chancroid  inoculation.  Clinically,  vaccinal  syphilis  has  furnished  am- 
ple opportunities  to  study  the  eii'ccts  of  hetero-inoculation — accidental 
it  is  true. 

Auto-inoculations  have  been  performed  without  number,  the 
result  (with  some  little  exception  to  be  mentioned  below)  having  been 
invariably  negative,  unless  the  chancre  had  been  previously  irritated 
by  friction,  savin-powder,  tartar-emetic,  or  other  irritant,  or  was  itself 
in  a  state  of  inflammation,  producing  pus.  Under  such  circumstances 
auto-inoculation  will  often  produce  a  pustule,  followed  by  a  small  ul- 
cer, remaining  open,  perhaps,  for  some  time,  furnishing  pus,  also  auto- 
inoculable,  but  this  ulcer  has  not  the  rapid  march  or  the  characteristic 
appearance  of  chancroid,  and  has  never  been  proved  to  be  such,  by 
being  inoculated  upon  a  healthy  individual  and  there  producing  a 
characteristic  chancroid  not  followed  by  syphilis.*  This  may  be  and 
has  been  done  by  inoculation  from  a  mixed  chancre,  but  never  from 
pure  syphilitic  chancre.  The  pustule  and  ulceration  produced  by 
auto-inoculation  of  chancre  are  similar  to  what  may  also  be  produced  by 
inoculation  of  pus  of  other  syphilitic  lesions,  or  sometimes  with  the 
pus  of  any  indifferent  abscess  ;  in  other  words,  they  are  the  pustule  and 
ulceration  of  simple  inflammatory  irritation,  not  the  special  poisonous 
sore  known  as  chancroid,  which  is  so  freely  inoculable  ;  and  as  simple 
dirt  and  irritation  may  call  out  a  mucous  patch  or  pustule  upon  a 
syphilitic  subject,  so  may  also  auto-inoculation  of  some  of  the  syphi- 
litic products. 

The  difference  between  the  inoculation  of  chancroid  and  syphilitic 
chancre  has  been  strikingly  illustrated  not  a  few  times.  The  three 
famous  cases  of  Lindmann,  Warnery,  and  Danielssen  are  perhaps  the 
most  conclusive.  Lindmann  inoculated  himself  a  number  of  times 
with  chancroidal  pus,  always  with  success,  but  with  no  syphilis ; 
finally,  as  the  doctrines  of  syphilization  were  in  vogue,  believing  him- 
self protected,  after  having  produced  a  dozen  chancroids,  he  inocu- 
lated himself  with  matter  taken  from  the  ulcerated  tonsils  of  a  syphi- 
litic friend.  This  was  followed  on  the  eleventh  day  by  a  papule  (not 
a  pustule,  as  after  the  previous  inoculations).  The  papule  ulcerated 
slightly,  and  in  forty-five  days  a  general  syphilitic  eruption  apj^eared. 
The  doctor  now  recommenced  his  inoculations  with  chancroid  matter, 
and  when  last  heard  from  was  still  continuing,  then  having  reached 
the  twenty-seven  hundredth  successful  chancroid  ulcer.  Warnery,  of 
Lausanne,  under  the  same  "  syphilization  "  delusion,  inoculated  him- 

*  I  have  given  this  point  considerable  attention  in  another  place,  "  Venereal  Diseases," 
1880,  p.  10  et  seq. 


504  SYPHILIS. 

self  plentifully  with  cliiincroitls,  which  took,  but  iiroclucecl  only  local 
ulcers.  Finally,  he  employed  the  syphilitic  virus  once,  and  an  indu- 
rated chancre  appeared  after  twenty-three  days'  incubation,  followed 
by  syphilis  in  due  course.  Daniclsseu,  a  discijile  of  syphilization,  in- 
oculated a  man,  who  had  elephantiasis,  two  hundred  and  eighty-seven 
times  with  chancroid,  until  be  had  temporarily  exhausted  the  irrita- 
bility of  the  skin,  and  no  more  chancroids  could  be  produced  by  inocu- 
lation. In  other  words,  the  patient  was  "  syphilized,"  as  it  is  called. 
Now,  one  inoculation  was  made  with  true  syphilitic  virus.  An  indu- 
rated, syphilitic  chancre  appeared,  and  in  sixt3'-eight  days  a  general 
syphilitic  eruption  followed.  Since  then  very  little  has  been  said  by 
its  advocates  of  "  syphilization  "  as  a  prophylactic. 

The  course  of  syphilitic  chancre  observed  by  hetero-inoc^ilation  is 
briefly  as  follows  :  A  chancre  is  always  produced  with  or  without  ul- 
ceration, a  mucous  patch  never,  although  certain  published  observa- 
tions state  the  contrary.  A  strict  analysis  of  these  cases  proves  that 
they  commenced  as  indurated  chancre,  and  became  mucous  patches 
only  secondarily  after  an  interval.  The  first  result  of  hetero-iuocula- 
tion  has  often  been  a  pustule,  just  such  a  little  fester  as  might  appear 
after  the  prick  of  a  pin,  but  this  pustule  heals  entirely  in  a  few  days. 
It  is  accidental,  and  in  most  instances  nothing  remains  to  mark  the 
inoculated  point  except  the  dry  speck  of  blood.  This  finally  rubs  off, 
and  the  skin  becomes  absolutely  normal.  No  change  occurs  for  a 
period  varying  from  ten  to  thirty-nine  days  in  the  re]iortcd  cases. 
Then  the  first  signs  of  chancre  appear,  not  as  in  chancroid  by  a  pus- 
tule, but  as  an  indurated  papule  (which,  becoming  larger,  may  be 
called  a  tubercle),  of  a  dark,  vinous-red  color,  without  pain,  or,  per- 
haps, with  a  little  itching.  This  may  remain  dry,  being  covered  after 
a  while  with  a  scaly  crust,  or  may,  and  usually  does,  ulcerate  after  a  few 
days,  often  scabbmg  secondarily.  The  epidermis  may  raise  as  a 
pustule  before  ulceration.  The  ulcer  has  sometimes  been  noted  as 
appearing  from  the  first,  but  usually  at  a  mean  of  five  days  after  the 
papule.  It  persists  for  a  variable  period,  several  weeks,  possibly 
months,  and,  getting  well,  leaves  often  a  pigmented  cicatrix  behind. 
The  neighboring  lymphatic  glands  indurate,  do  not  sujipurate,  and 
general  syphilis  follows. 

This  is  the  course  with  no  appreciable  variation,  no  matter  what 
fluid  is  inoculated  —  chancre  secretion,  pus  from  mucous  patch, 
blood,  or  other  discharge. 

An  apparent  exception  to  the  above  course  exists  for  vaccinal  chan- 
cre, where  chancre-virus  or  syphilitic  blood  is  introduced  along  with 
vaccine  virus.  Here  the  vaccine  virus,  having  a  shorter  incubation 
than  the  syphilitic,  develops  sooner,  and  the  vesicle  runs  along  regu- 
larly, perhaps,  at  first,  but  varies  from  the  true  type  after  a  time,  in 
that  the  base  indurates  and  the  surface  ulcerates  ;  or,  perhaps,  it  may 


MULTIPLE   INOCULATION.  505 

scab,  the  whole  resembling  a  large,  scabbed,  ecthymatous  pustule. 
Sometimes  only  the  syphilitic  virus  takes,  when,  after  a  long  incuba- 
tion, the  regular  papulo-tubercle  of  syphilitic  incubation  appears  and 
runs  its  usual  chronic  course  ;  or  the  vaccine  vesicle  may  be  imperfect 
and  abortive,  the  sore  soon  putting  on  the  appearance  of  a  cutaneous 
chancre,  and  general  syphilis  following  in  due  course. 

There  is  one  source  of  error  in  regard  to  vaccinal  syphilis  ;  namely, 
that  the  vaccinal  fever  may  develop  latent,  possibly  unsuspected,  syphi- 
lis from  which  a  child  is  already  suffering  by  inheritance  or  previous 
contagion.  Here  the  vaccination  will  always  be  accused  of  being  the 
cause  of  the  syphilis.  The  distinction  is  easy.  If  vaccination  devel- 
ops latent  syphilis,  it  does  so  as  does  the  application  of  a  blister  or 
other  irritant,  and  a  more  or  less  general  eruption  comes  on  quickly, 
usually  starting  from  the  point  of  irritation,  vaccinal  or  other ;  where- 
as, in  true  vaccinal  syphilis,  there  is  first  a  period  of  incubation,  then 
a  local  chancre,  then  indurated  glands,  and  after  a  second  incubation 
a  general  (at  once)  syphilitic  eruption,  which  does  not  tend  to  start 
from  the  irritated  point.  Chancres  of  inoculation  are  of  course  liable 
to  the  same  complications  as  chancre  naturally  acquired. 

When  the  inoculating  fluid  is  rubbed  upon  a  scarified  or  a  blis- 
tered surface,  the  lesion  appears  multiple  at  first,  many  little  papules 
springing  up  in  the  patch,  as  if  many  separate  points  had  been  simul- 
taneously inoculated,  which  is,  indeed,  the  case  ;  these,  however,  soon 
coalesce  into  one  mass,  forming  one  lumpy,  tubercular  chancre-patch. 
This  explains  at  once  how  syphilitic  chancre  may  be  multiple,  several 
different  points  having  been  inoculated  at  the  same  or  nearly  the  same 
time. 

Multiple  In-qculation. — In  testing  this  point  it  has  been  found 
that,  where  many  points  were  inoculated  at  the  same  time,  usually  all 
took  and  appeared  simultaneously  as  chancres.  "Where  the  intervals  of 
inoculation  were  a  few  days  apart  upon  the  same  individual,  nearly  all 
took.  Puche  inoculated  twice  at  twenty-two  days'  interval ;  chancre 
appeared  upon  both  points  at  the  same  time.  In  other  cases  the  sec- 
ond inoculations  have  appeared  to  require  a  longer  incubation  than 
the  first.  Again,  inoculations  made  upon  different  individuals,  with 
virus  derived  from. the  same  lesion,  have  required  different,  periods 
of  incubation  for  their  development. 

These  apparent  exceptions  to  the  fact  first  noted  by  Hunter,  that 
syphilis  was  not  reinoculable  upon  an  already  infected  person,  are  still 
further  borne  out  by  the  results  of  other  experiments,  such  as  those  of 
Wallace,  who  produced  an  indurated  chancre  by  using  chancre-virus 
upon  a  man  who  had  reached  the  eruptive  stage  of  the  disease.  Wal- 
lace, Bidenkap,  Sperino,  Lee,  and  others,  have  performed  auto-inocu- 
lation soon  after  the  appearance  of  chancre,  in  some  cases  with  suc- 
cess, producing  a  small,  ill-defined,  indurated  chancre,  usually  with 


506  SYPUILIS. 

short  incubation.  Fonrnier  and  Pnclie  believe  that  about  two  ]icr 
cent,  of  auto-inoculations  of  syphilitic  chancre  take,  presumably  when 
some  irritation  (inflammatory)  of  the  chancre  exists,  but  the  vast  ma- 
jority, especially  where  the  chancre  is  fully  developed,  3'ield  only  nega- 
tive results,  and  in  no  case  does  the  auto-inoculation  of  syjjhilitic 
chancre  produce  the  pustule  and  rapidly  advancing  characteristic  ulcer 
known  as  chancroid. 

The  rule,  then,  is  practically  this  :  reinoculations  of  syphilitic  virus 
upon  patients  already  syphilitic  i)roducc  no  result.  Auto-  or  hetero- 
inoculation  u])on  a  patient  with  very  young  chancre  is  occasionally 
successful.  A  more  constantly  favorable  result  might  be  expected 
from  hetero-inoculation  during  the  late  tertiary  stage  of  the  disease. 
At  both  of  these  periods  the  patient  is  not  fully  protected,  the  system 
not  being  saturated  with  the  syphilitic  poison  at  first,  and  the  virus 
being  at  a  minimum  toward  the  end.  Between  these  periods  very 
rarely  will  reinoculation  of  any  syphilitic  virus  produce  any  effect, 
although  an  irritative  ulceration  may  be  produced  in  some  subjects 
by  the  inoculation  of  any  inflammatory  pus,  and  chancroid  is  inocula- 
ble  at  will  in  its  full  vigor  on  all  subjects. 

This  subject  finds  an  apt  and  analogous  illustration  in  the  results 
of  inoculation  Avith  vaccine  virus.  Any  number  of  such  inoculations 
made  at  the  same  time  may  take  fully.  Eeinoculations  practiced  be- 
fore the  first  inoculation  has  taken,  or  while  the  vesicle  is  young,  will 
also  yield  positive  results,  but  to  a  less  degree.  Then,  while  the  pro- 
tecting power  of  the  virus  lasts,  the  result  is  invariably  negative,  or 
only  abortive  pustules  are  produced  (false  takes).  Finally,  after  a 
variable  period  the  protection  becomes  weak  or  exhausted,  and  inocu- 
lation produces  a  partial  or  even  perfect  result. 

Secretions  capable  of  transmitting  Syphilis  hy  Inoculation. — This 
subject  has  been  carefully  studied  by  inoculations,  as  well  as  clinically 
by  confrontations,  that  is,  by  examination  of  the  individual  from 
whom  a  given  patient  acquired  his  syphilis,  and  comparing  the  lesions. 
The  first  confrontations  of  syphilitic  chancre  were  made  in  1852,  by 
Bassereau.*  Later,  the  confrontations  of  Diday,  Eodet,  Fournier, 
Clerc,  Musset,  Eollet,  were  published  by  Dron.f  Fournier  %  followed, 
and  numerous  other  contributions,  since  made,  furnish  in  all  a  very 
full  collection  from  which  to  draw  deductions.*  The  results  arrived 
at  have  been  identical.  Inoculations  of  healthy  subjects  with  the 
fluid  secreted  by  syphilitic  chancre,  mucous  patches,  any  secondary 
cutaneous  or  mucous  lesion  yielding  a  discharge,  and  of  syphilitic 
blood  (Pellizari,  Waller,  Lindwiirm,  Gibert,  and  the  anonymous  Palati- 

*  "  Des  Maladies  de  la  Peau  symptomatiques  dc  la  Syphilis,"  Paris, 
•f-  "These  de  Paris,"  1856.  %  Ricord's  "Lc9ons  sur  le  Chancre,"  1858. 

»  RoUet,  "  De  la  Syphilis  inocule6,"  "  Ann.  de  Derm,  et  dc  Syph.,"  IS'ZS-'Y*,  No.  5,  pp. 
330-355. 


FLUIDS  CAPABLE  OF  COMMUNICATING  SYPHILIS.  507 

nate)  drawn  from  a  patient  with  an  eruption,  taken  eitlicr  from  a 
papule  or  tubercle,  or  from  the  healthy  skin  between  the  lesions — all 
such  inoculations  yield  indurated  chancre  aft.er  a  period  of  incubation, 
■which  chancre  is  succeeded  by  general  syphilis.  Whether  the  blood 
of  syphilis  is  poisonous  in  the  -intermediary  periods  between  the  erup- 
tions, when  the  skin  and  mucous  membranes  are  sound,  is  not  yet 
established,  but  certain  observations  of  vaccinal  syphilis  would  go  to 
prove  that  it  is,  as  well  as  the  recent  case  reported,  in  which  skin-graft- 
ing has  produced  the  disease  (Deubel  *),  a  very  doubtful  case  reported 
by  Fereol.  Another  case  has  also  been  reported,  the  name  and  refer- 
ence to  which  I  have  mislaid. 

The  secretions  of  other  pathological  lesions  not  syphilitic  will  not 
produce  syphilis  unless  some  of  the  patient's  blood  be  inoculated  at  the 
same  time.  Gonorrhoea,  acquired  from  a  syphilitic  patient  having  at 
the  time  only  gonorrhoea,  reproduces  itself  as  gonorrhoea,  and  not  as 
syphilis.  The  same  is  true  of  chancroid,  even  by  inoculation,  if  no 
syphilitic  blood  be  inoculated  along  with  the  pus.  Certain  confronta- 
tions and  inoculations  of  mixed  chancre  go  to  prove  that  from  such  a 
sore  may  be  derived  either  simple  chancroid  or  mixed  poisonous  chan- 
cre. Diday  inoculated  pus  from  a  pustule  of  acne  produced  upon  a 
patient  "  in  full  syphilis "  by  the  administration  of  iodide  of  potas- 
sium. The  result  was  negative.  The  same  is  true  of  the  vaccine 
virus.  Pure  vaccine  virus,  taken  from  a  syphilitic  patient  before 
there  is  any  pus  in  the  vesicle,  will  produce  vaccinia  only,  if  no  blood 
is  inoculated.  This  is  well  shown  in  some  of  the  vaccino-syphilitic 
epidemics,  where  many  children  were  vaccinated  at  the  same  sitting, 
from  the  same  child,  the  virus  being  taken  from  arm  to  arm.  Often, 
in  such  cases,  the  result  has  been  that  those  first  vaccinated  developed 
vaccinia  only  and  no  syphilis  ;  others  a  little  later,  when  the  virus  was 
giving  out,  developed  vaccinia,  followed  by  indurated  chancre  on  the 
same  spot,  usually  before  the  vaccine  pustule  got  well ;  finally,  those 
last  vaccinated  developed  only  an  abortive  vaccine  vesicle  or  none  at  all, 
while  indurated  chancre  appeared  after  incubation  upon  the  vaccinated 
spot,  and  general  syphilis  followed.  The  recent  important  case  of 
Dr.  Cory  deserves  mention  here.  After  three  negative  experiments, 
this  gentleman  finally  succeeded  in  inoculating  himself  with  syphilis, 
using  pure  lymph  without  any  blood — at  least,  so  it  is  alleged.  The 
committee  appointed  (Drs.  Humphrey,  Ballard,  and  Hutchinson)  to 
examine  into  these  experiments  report f  it  as  their  opinion  ^'that  it  is 
possible  for  syphilis  to  be  communicated  in  vaccination  from  a  vaccine 
vesicle  on  a  syphilitic  person  notwithstanding  that  the  operation  be  per- 
formed with  the  utmost  care  to  avoid  the  admixture  of  blood."  This 
report  seems  to  read  between  the  lines  that  the  committee  thought 

*  "Gaz.  Med.  de  Paris,"  November  5,  ISSl. 

f  "New  York  Medical  Record,"  editorially  (citing  "  Brit.  Med.  Journ."),  June  21,  ISSi. 


508  SYPHILIS. 

that  Dr.  Cory,  in  sjiite  of  his  care,  did  get  a  little  blood  mixed  with 
his  lymph. 

The  long  and  imjiortant  subject  of  yacciual  syphilis  can  not  be 
discussed  here  for  want  of  space.  Suffice  it  to  say,  syphilis  can  be 
communicated  by  vaccination,  but  only,  t^o  far  as  has  yet  been  clearly 
proved,  when  blood  has  become  mingled  with  the  vaccine  lymph, 
or  where  a  true  chancre  lies  hidden  under  the  vaccine  vesicle  and 
mingles  its  discharge  with  the  vaccine  lymph.  If  pure  lymph  be 
taken  early,  neither  does  chancre  follow  at  the  vaccinated  point 
nor  syphilis  afterward  ;  but,  since  a  little  blood  may  readily  be  mixed 
with  the  lymph  and  not  be  perceived,  no  amount  of  caution  is  too 
great,  and  in  no  case  should  vaccine  lymph,  derived  from  an  in- 
dividual even  remotely  suspected  of  being  syphilitic,  be  employed.* 
If  not  the  lymph,  much  less  should  the  vaccine  scab  be  used,  as  it 
necessarily  contains,  besides  vaccine  lymph,  both  pus  and  blood,  and 
a  portion  of  the  solid  tissue  of  the  skin  of  the  individual  from  whom 
it  was  taken.  The  natural  conclusion  is  that  it  is  wiser  always  to  use 
lymph  from  the  calf  and  never  humanized  virus  ;  and,  as  pure  virus 
in  sealed  tubes  can  now  be  sent  from  the  vaccinal  farms  over  the  entire 
globe,  remaining  good  in  any  climate,  there  is  no  necessity  of  taking 
risk  in  any  case. 

Inoculation  has  failed  to  produce  positive  results  from  ulcers  of  the 
late  tertiary  period  of  syphilis.  Diday  f  inoculated  sixteen  times  with 
blood  from  patients  suffering  from  tertiary  syphilis  (nodes),  always 
with  negative  results.  The  fact  that  patients  with  tertiary  syphilis 
may  occasionally  accpiire  a  chancre  and  the  earlier  eruptions  anew,  and 
the  other  undoubted  fact  that  such  patients  may  procreate  healthy 
offspring,  render  it  still  more  certain  that  late  tertiary  syphilis  is  no 
longer  either  communicable  or  transmissible.  Bumstcad  mentions 
one  case  of  probable  transmission  of  syphilis  by  inoculation  from  blood 
in  the  tertiary  stage.  The  victim  was  a  surgeon  of  Ohio,  who  reports 
that  he  inoculated  an  abrasion  on  his  finger  while  operating  upon  a 
case  of  syphilitic  necrosis  of  the  skull.  Chancre  and  general  syphilis 
followed  in  due  course,  A  case  of  this  sort  needs  wide  confirmation, 
for  a  surgeon  with  a  wounded  finger  runs  so  many  risks  of  contagion 
from  sources  which  he  hardly  suspects,  that  it  is  rather  a  matter  of 
surprise  that  all  surgeons  do  not  become  sooner  or  later  inoculated  in 
some  accidental  manner  from  a  source  unknown  to  themselves,  a  cir- 
cumstance which  has  happened  surely  to  several  surgeons  who  have 
communicated  the  fact  to  me  and  shown  me  the  initial  lesion  upon  the 
finger.    As  for  transmission,  on  the  other  hand,  women  who  have  posi- 

*  Hutchinson  has  published  an  admirable  set  of  personal  cases  of  vaccino-syphilis 
with  his  characteristic  clearness  and  thoroughness,  in  his  "  Illustrations  of  Clinical  Sur- 
gery," fascic.  vi,  London,  1877. 

t  "  Gazette  Medicalc,"  1849. 


METHODS  OF  TRANSMISSION.  509 

tivc  tertiary  symptoms  undoubtedly  procreate  diseased  cliildron  some- 
times, just  as  they  as  certainly  often  produce  healthy  ones.  Ilonce, 
tertiary  syphilis  may  be  said  to  be  generally,  but  not  always,  free  from 
the  dangers  of  transmission  and  of  communicability.  The  older  the 
disease,  the  less  apt  it  is  to  be  transmitted.  The  male  loses  the  power 
of  transmission  seemingly  long  before  the  female. 

None  of  the  physiological  secretions  or  excretions  can  produce 
syphilis  by  inoculation.  Mucus  from  the  mouth  of  a  syphilitic  patient 
having  no  lesions  of  the  mucous  membrane  at  the  time  has  been  tested 
often.  Profeta,  of  Palermo,  and  Diday  *  have  inoculated  saliva  with- 
out success.  If  mucous  patches  exist,  then  the  saliva  produces  chan- 
cre when  inoculated,  as  shown  by  the  interesting  cases  of  tattooing  re- 
ported by  Maury  and  Dulles,  f  Yidal  *  has  proved  the  harmlessness  of 
tears,  and  the  sweat  and  urine  have  been  in  a  similar  way  relieved  of 
blame.  The  semen  has  been  inoculated  by  Mireur,  J  taken  from  a 
man  in  the  full  bloom  of  secondary  eruptive  disease.  Milk  from  a 
syphilitic  woman  is  neither  inoculable  experimentally  nor  does  it 
give  the  disease  to  the  child  who  drinks  it.  Voss's  *  three  cases  are 
always  referred  to.  Two  of  them  received  a  Pravaz's  syringeful  of 
milk  subcutaneously,  and  nothing  ha^jpened.  The  other  got  a  local 
abscess,  and  in  five  days  after  the  appearance  of  this  alleged  chancre  a 
syphilitic  eruption  appeared.  This  short  (five-day)  secondary  incu- 
bation immediately  deprives  the  case  of  all  value.  Padova  and  Profeta 
have  failed  to  inoculate  syphilis  by  using  milk.  Ajjparent  infections 
by  milk,  without  any  recorded  primary  lesion  (Melchior  Robert,  Lane, 
Parker,  Mahon,  Bell,  and  others),  are  set  off  by  other  carefully  ob- 
served cases,  where  children  suckled  by  a  syphilitic  nurse  have  escaped 
disease,  even  where  the  nurse  had  a  specific  lesion  of  the  nijDple 
(Duges,  Eicord,  Cullevier,  Nonat,  Vernot,  and  others).  Where  the 
nurse  has  a  syphilitic  lesion  of  the  nipple,  the  child  surely  becomes 
poisoned  if  it  have  a  fissure  or  other  abrasion  of  the  lips  through 
wdiich  the  poison  can  be  absorbed ;  but  in  such  case  syphilis  in  the 
child  is  always  preceded  by  chancre  of  the  lips  or  mouth.  Cerasi's  || 
case  of  alleged  transmission  of  syphilis  by  milk  to  a  child  carries  its 
own  condemnation  with  it,  since  the  lesions  found  on  autopsy  were 
those  of  inherited  disease. 

Methods  of  Traistsmissiois"  of  Syphilis. — Syphilis  always  com- 
mences as  a  chancre,  with  two  exceptions — or  rather  one  alleged  ex- 

*  Cited  by  Gallois,  "  Recherches  sur  la  question  de  I'innocuite  du  lait  provenant  des 
nourrices  syphilitiques,"  These  de  Paris,  18*77. 

f  "Am.  Jour.  Med.  Sci.,"  January,  18*77,  p.  44. 

X  "Ann.  de  Derm,  et  de  Syph.,"  No.  6,  t.  viii,  1877. 

*"St.  Petersburger  med.  Wochenschrift,"  No.  23,  1876,  and  "Brit.  Med.  Journ.," 
November  11,  1876. 

II  "Gaz.  di  Roma,"  July,  1878,  and  "  Jahresb  f.  gesmmt.  Med.,"  Bd.  ii,  Abt.  11, 
1878,  p.  520. 


510  SYPHILIS. 

ception,  for  the  matter  is  not  yet  successfully  proved,  namely,  the  clioc- 
en-rctour  ;  the  other  a  real  exception — that  of  inherited  disease. 

Choc-en-retour. — This  is  a  misty  condition,  prohably  only  a  high- 
sounding  title  to  conceal  ignorance.  In  it  the  ovule  of  a  healthy 
woman  is  supposed  to  be  infected  with  syphilis  by  the  semen  of  the 
syphilitic  father,  a  semen  which  the  direct  test  of  inoculation  proves 
to  be  void  of  any  poison.  The  syi)hilitic  germ  grows,  and  in  its  turn 
poisons  the  mother,  who  thus  becomes  diseased  without  the  necessity  of 
having  any  primary  lesion.  The  evidence  on  this  point  consists  in 
reported  cases  wherein  no  chancre  has  been  observed,  but,  unfortu- 
nately, all  such  evidence,  no  matter  how  much  there  may  be  of  it,  is 
negative  at  best.  We  must  accept  practically  the  fact  that  many  a 
woman,  possibly  the  greater  number  having  syphilis,  gets  the  disease 
without  it  having  been  possible  for  the  physician  to  have  seen  the 
primary  lesion,  yet  this  does  not  prove  that  she  never  had  it.  And  it 
is  also  true  that  many  a  woman  has  a  syphilitic  child,  but  no  symptoms 
herself  at  that  time,  and  none  for  a  long  time  afterward,  when  she 
becomes  plainly  syphilitic  in  her  symptoms.  This  is  choc-cn-rctovr, 
but  no  one  can  possibly  say  that  this  woman  may  not  have  had  a  local 
lesion  at  some  time  without  knowing  or  suspecting  it  herself  ;  so  that, 
while  we  accept  the  facts  practically,  we  need  not  accept  the  expla- 
nation of  clioc-en-retour  scientifically,  since  it  does  not  appear  very 
reasonable,  and  particularly  until  the  question  of  the  possibility  of 
infection  of  the  child  by  the  father,  the  mother  remaining  sound,  has 
been  finally  settled.  The  semen  being  harmless  by  inoculation,  if  it 
finally  becomes  proved  (as  it  may  well  be)  that  the  mother  remaining 
healthy  the  child  is  healthy  whether  the  father  is  syphilitic  or  not, 
in  such  case  the  scientific  explanation  of  clioc-en-retour  falls  to  the 
gi'ound  of  necessity. 

Inherited  Syphilis. — When  a  child  is  born  with  inherited  s\'philis, 
it  naturally  never  has  had  a  chancre — a  primary  lesion.  No  one 
doubts  that  a  mother  in  active  syphilis  aborts,  miscarries,  or  jiroduces 
a  diseased  child.  As  to  whether  the  father  can  produce  a  diseased 
child  by  infecting  the  ovum  through  impregnation  without  infecting 
the  mother  (and  through  her  the  ovum),  this  is  a  question  upon  which 
there  is  much  controversy  to-day,  and  which  is  not  yet  settled  in  spite 
of  the  able  contributions  to  the  subject  made  by  many  competent  ob- 
servers. That  a  father  may  have  syphilis  and  still  have  a  healthy 
child  is  proved  by  Mireur.*     The  same  author  demonstrates  that 

*  Hippolyte  Mireur  has  collated  the  evidence  on  the  subject  under  discussion  in  an 
admirable  essay,  "  Sur  rilerodite  de  la  Syphilis,"  Paris,  1867.  He  leans  toward  the  belief 
that,  if  the  mother  escape,  a  syphilitic  father  can  not  produce  a  syphilitic  child.  He  gives 
the  following  case  (page  26) :  About  a  year  after  contracting  chancre,  followed  by  well- 
marked  secondary  symptoms,  which  had  disappeared  entirely  under  treatment,  M.  C 

married.    Ten  months  afterward  his  wife  was  delivered  of  a  vigorous,  healthy  child,  "  the 


METHODS   OF   TRANSMISSION.  511 

both  parents  may  still  suffer  from  tertiary  lesions,  and  produce  seem- 
ingly healthy  children.  When  the  mother  has  syphilis,  it  has  been 
shown  that  she  may  have  a  healthy  child  while  under  treatment,  and  a 
diseased  one  if  the  treatment  be  left  off  before  she  has  passed  the  viru- 
lent stage  of  the  disease.  This  is  demonstrated  by  Thurman's  case.* 
In  this  case  the  virulence  of  the  disease  seems  to  have  extended  over 
an  exceptionally  long  period.  Ricord  and  Baerensprung  believe  that 
the  child  is  rarely  if  ever  infected  if  the  mother  acquire  her  disease 
after  the  seventh  month  of  pregnancy.  Chabalier's  case  f  bears  upon 
this  point.  Finally,  that  a  man  himself  syphilitic,  with  a  syphilitic 
wife  and  a  non-syphilitic  mistress,  may  have  a  diseased  child  by  the 
former  and  a  healthy  child  by  the  latter — a  child  known  to  be  his  by 
an  inherited  peculiarity  of  the  thumbs — the  two  children  being  born 
within  fifteen  days  ,of  each  other,  seems  to  be  fully  proved  by  Char- 
rier's  case.^ 

Much,  very  much,  has  been  written  upon  this  truly  interesting  sub- 
image  of  his  father,"  who  remained  perfectly  well  up  to  the  age  of  two  years.  At  thi3 
date  a  little  indolent  erosion  appeared  upon  the  lip  of  the  father.  The  latter  paid  no 
attention  to  it,  but  continued  to  fondle  and  kiss  his  child.  After  a  time  there  appeared 
upon  the  lip  of  the  child  a  livid,  indurated  excoriation,  one  centimetre  in  diameter,  accom- 
panied by  indolent  bubo  under  the  jaw.  After  a  time,  in  spite  of  treatment,  the  child 
developed  a  characteristic  syphilitic  roseola  and  mucous  patches  at  the  anus. 

Mireur  (page  91)  relates  the  case  of  a  syphilitic  mother  and  father,  where  the  dis- 
ease ran  its  course  without  specific  treatment.  After  two  miscarriages  and  a  still-birth 
at  term,  the  fourth  and  fifth  children  were  born  alive,  but  developed  syphilitic  eruptions 
shortly  and  died.  The  sixth  and  seventh  children  were  born  healthy  and  continued  well, 
notwithstanding  the  fact  that  both  father  and  mother  had  subsequently  "  gummy  tubercles 
and  ulcers  scattered  abundantly  over  the  extremities,"  for  which  they  finally  placed  them- 
selves under  specific  treatment. 

*  In  Thurman's  case  ("  Journ.  de  Med.  et  de  Chir.,"  Toulouse,  October,  1851),  two 
syphiUtics  were  married.  Both  had  been  treated,  apparently  recovered,  and  never  after- 
ward, while  under  observation,  manifested  any  sj-mptoras  of  syphilis.  Seven  children 
were  born,  became  covered  with  a  syphilitic  eruption,  and  died.  Pregnant  for  the  eighth 
time,  the  mother  was  brought  under  the  influence  of  mercury.  The  child  was  bom 
healthy,  and  grew  up  sound.  Pregnant  for  the  ninth  time,  the  treatment  of  the  mother 
was  repeated,  a  healthy  child  resulted,  who  remained  well.  Pregnant  for  the  tenth  time, 
treatment  was  neglected.  A  child  was  bom,  seemingly  well  at  first,  who  developed  a 
syphilitic  eruption,  and  died  after  six  months.  In  her  eleventh  pregnancy  the  mother 
again  took  mercury.     A  healthy  child  was  born,  who  remained  well. 

f  In  Chabalier's  case  ("  Journ  de  Med.  de  Lyon,"  May,  1S64),  Madame  X ,  at  the 

end  of  the  seventh  month  of  pregnancy,  had  intercourse  with  her  husband,  who  had  been 
traveling  for  five  months.  Thirty-eight  days  afterward  (during  the  ninth  month  of  preg- 
nancy) Chabalier  found  three  indurated  chancres  on  the  vulva.  The  child  was  bom  at 
term,  seemingly  healthy,  and  was  immediately  given  to  a  healthy  wet-nurse.  One  month 
after  confinement  the  mother  left  her  child  to  join  her  husband  on  his  travels.  At  the  end 
of  six  weeks  Chabalier  was  called  to  see  the  infant.  He  found  it  covered  with  a  papulo- 
vesicular eruption,  with  intense  coryza,  and  mucous  patches  on  the  scrotum  and  in  the 
mouth.  At  the  same  date  the  mother,  while  traveling,  developed  mucous  patches  at  the 
vulva  and  anus.     The  child  died. 

X  "Archives  Gen.  de  Med.,"  1862,  vol.  ii,  p.  324. 


512  SYPHILIS. 

jcct,  and  it  has  been  strongly  asserted  that  syphilis  may  be  communi- 
cated by  the  father  to  his  child,  the  mother  remaining  sound.  This 
side  of  the  question  has,  pcrhai)S,  its  ablest  advocate  in  Kassowitz,* 
while  one  of  tlie  stillest  upholders  of  the  other  side  of  the  question — 
namely,  a  healthy  mother  a  healthy  child,  so  far  as  syphilis  is  con- 
cerned, no  matter  what  the  condition  of  the  father  as  to  that  jiarticu- 
lar  disease — is  Adam  Oewre,  of  Christiania,  whose  writings  through 
translations  and  reviews  are  well  known  to  every  one  familiar  with  the 
modern  literature  of  syphilis.  A  host  of  other  writers,  of  greater  or 
less  merit,  swell  the  list  with  individual  cases  and  comments.  I  can 
not  pretend  to  do  the  subject  full  literary  justice  here,  and  will  not 
attemi3t  it.  I  simply  record  my  own  convictions,  or,  rather,  serious 
impressions,  for  I  am  open  to  other  convictions  when  the  weight  of 
evidence  changes.  The  great  stumbling-blocks  to  me,  standing  in  the 
way  of  my  seriously  accej^tiug  the  fact  that  a  child  may  be  born  syphi- 
litic and  still  have  a  healthy  mother,  are  the  failure  of  direct  inocula- 
tion upon  such  mothers,  and  the  so-called  Colles's  law,f  namely,  a 
child  born  syphilitic  can  not  poison  its  own  mother,  but  may  poison 
a  healthy  wet-nurse.  Caspary,J  so  far  as  I  know,  is  the  only  one  who 
has  directly  inoculated  a  mother  sujiposed  to  be  healthy,  but  who 
miscarried  of  a  S3'philitic  offspring,  the  father  being  syphilitic.  In 
this  case  four  inoculations  on  the  arm  with  the  secretion  from  broad 
condylomata  mixed  with  blood  failed  to  take.  As  to  Colles's  law,  none 
of  Kassowitz's  forty-three  presumably  healthy  mothers,  although 
having  and  living  among  syphilitic  children,  are  reported  to  have  be- 
come diseased,  and  no  one  among  the  numerous  supporters  of  that  side 
of  the  question  has  yet  brought  forward  an  alleged  healthy  mother  of 
a  syi)hilitic  child  who  has  afterward  herself  in  any  way  become  syphi- 
litic. The  cases  cited  by  Kassowitz  in  controversion  will  not  bear 
close  scrutiny.  Cazenave's  case  is  only  one  of  the  old  cases  cited  by 
Colics  himself  and  commented  on  by  Cazenave.  Brizio  Cochi's  case 
proves,  if  anything,  a  syphilitic  father,  a  syphilitic  mother  who  has 
no  noticeable  secondary  symptoms  (a  circumstance  not  very  uncom- 
mon), finally,  an  ulcerated  nipple  on  account  of  nursing,  and  the  acci- 
dental outbreak  of  tertiary  symptoms.  I  have  had  a  case  wherein  an 
oldish  woman  came  to  me  with  tertiary  syphilitic  ulceration  in  the 
nose  and  throat  with  loss  of  bone,  and  a  gumma  on  the  cheek  with 
loss  of  bone,  together  with  tertiary  eye-lesions.  She  had  never  been 
treated  for  any  disease,  always  having  been  well,  but  she  narrated  with 
tears  in  her  eyes  how  she  was  childless,  having  lost  a  number  of  chil- 
dren through  abortion,  miscarriage,  and  early  death  of  the  offspring, 

*  "  Die  Ycrerbung  der  Syphilis,"  Braumiiller  Wicn,  1876. 

f  Abraham  CoUes,  "  Practical  Observations  on  the  Venereal  Disease  and  on  the  Use 
of  Mercury,"  London,  1837,  p.  285. 

X  "  Vierteljahrsschrift  fiir  Derm,  und  Syph.,"  Ilefl  iv,  1875,  p.  437. 


METHODS  OF  TRANSMISSION.  513 

and  how  she  remembered  that  lier  liusband  had  a  bad  skin  disease,  was 
a  great  drinicer,  and  was  constantly  taking  medicine  for  a  disease 
about  which  she  knew  nothing.  >Slie  had  no  idea  that  either  he  or 
she  had  or  had  had  syphilis  until  I  told  her.  Medicine  promptly 
cured  her  lesions,  but  she  never  could  forgive  her  husband  because  he 
had  not  told  her  the  nature  of  his  disease  (she  had  been  always  well) 
in  order  that  she  might  have  been  treated,  and  so,  perhaps,  have  saved 
for  her  old  age  one  of  her  babies,  whom  she  hotly  lamented  in  all 
honesty.  Miiller's  case  is  not  clear  enough  to  require  comment. 
The  same  remark  applies  to  Guibout's  case — nothing  is  clear  about  it, 
no  subsequent  history  of  the  mother  to  prove  that  she  had  syphilis 
after  her  alleged  chancres  of  the  nipple.  Eanke  *  has  brought  forward 
the  only  case  which  seems  to  prove  what  is  claimed.  The  father,  of 
thirty,  had  had  syphilis  at  nineteen,  and  no  symptoms  for  nine  years. 
This  is  peculiar.  If  such  a  man  may  not  marry  with  impunity,  then 
no  one  can,  and  the  profession  to  be  honest  must  condemn  every 
syphilitic  to  celibacy.  It  is  alleged  that  a  syphilitic  child  is  born  one 
year  after  marriage  ;  another,  two  years  later.  The  latter,  at  the  age 
of  two  weeks,  gets  ulcers  in  the  mouth  and  a  spotted  eruption.  The 
mother  suckles  it,  and  gets  what  Kanke  considers  a  hard  chancre  at 
the  nipple,  followed  by  a  mottled  eruption.  This  disappeared  under 
mercurial  treatment,  and  a  relapse  got  well  in  the  same  manner.  The 
father  and  elder  child  remained  well,  l^o  one  had  been  employed  to 
draw  the  breast.  This  case  is  peculiar.  Did  the  mother  nurse  the 
first  child  ?  How  did  the  father,  being  and  remaining  well  for  nine 
years,  his  syphilis  being  eleven  years  old,  succeed  in  giving  his  chil- 
dren syphilis  ?  Who  vouches  for  the  purity  of  the  wife — or,  indeed, 
for  the  fact  that  she  did  not  have  syphilis  before  either  child  was 
born  ? 

This  is  really  the  weak  spot  in  the  case.  So  many  motives  make 
it  impossible  to  get  at  the  bottom  facts  in  the  case  of  a  woman. 
For  instance,  the  following  case  is  personal  to  me,  and  many  physi- 
cians can  doubtless  duplicate  it.  A  young  lady  in  good  social  stand- 
ing is  engaged  to  marry  a  man,  who  seduces  her,  and  brings  her  to  me 
with  a  chancre  on  the  vulva  followed  by  roseola,  glandular  engorge- 
ment, mucous  patches,  etc.,  all  of  mild  type,  but  well  marked.  The 
lover's  symptoms  were  more  severe.  I  treat  this  lady  for  two  and  a 
half  years,  her  family  and  friends  being  in  total  ignorance  that  she  is 
in  any  way  ill.  Her  lover  breaks  oS  his  engagement  with  her  after  the 
first  few  months,  and  after  the  first  roseola  she  never  has  any  symp- 
toms except  a  few  mouth-spots.  She  has  now  long  since  ceased 
treatment,  and  looks  the  picture  of  radiant  health.  If  such  a  pa- 
tient had  married  a  man  who  had  been  syphilitic  eleven  years  before 
and  well  for  nine  years,  no  power  could  draw  from  her  a  confession 

*  "  Mediciniscb-chirursrisches  Centralblatt,"  Aus.  S,  1S79,  p.  374. 
33  ^     >         .1 


514  SYPHILIS, 

that  she  had  liad  syphilis  before  marriage.  She  miglit  suckle  her 
child,  get  an  ulcerated  fissure  at  tiie  nipple,  and  a  rash  might  appear 
upon  her,  and  I  am  constrained  to  believe  that  such  a  set  of  circum- 
stances is  more  likely  to  have  obtained  in  Ranke's  case  than  that  his 
case  should  demonstrate  what  thousands  of  others  have  failed  to  prove. 

A  single  exception  contrary  to  all  experience  proves  nothing.  We 
must  simply  set  it  down  as  an  exception  which  our  feeble  perceptive 
powers  can  not  grapple  with,  otlierwisc  we  must  conclude  that  a  child 
may  have  inherited  syphilis  when  ncitlicr  of  its  parents  have  had  the 
disease,  for  Dujardin-Beaumetz  reports  a  case  which,  having  an  intense 
macular  and  ulcerative  sy])hilide.  died.  Parrot  found  characteristic 
osteophytic  growths  on  the  cranial  bones,  of  the  usual  rosy  tint,  due  to 
inherited  syphilis,  and  characteristic  changes  in  the  epiphyseal  carti- 
lages, yet  the  mother  of  this  child  tvas perfectly  healthy,  mid  alioays  had 
been  so,  as  was  and  had  been  the  husband,  and  they  had  had  five  healthy 
living  children.  "What  can  any  one  say  to  this  case,  except  that  the 
mother  in  some  manner  acquired  syphilis  after  the  birth  of  her  fifth 
child,  and  through  ignorance  or  for  some  other  reason  denied  the 
fact  ?    There  is  no  other  exi^lanation  possible  in  my  opinion. 

Scareuzio's  case  I  have  not  been  able  to  see  in  the  original.  Hyde  * 
cites  it — the  child  at  the  age  of  seven  mouths  being  alleged  to  have 
given  its  mother  chancre  on  the  nipple  followed  by  papular  syphilide 
and  mucous  patches.  The  child  was  seven  months  old  at  the  time, 
and  had  had  plenty  of  opportunity  to  acquire  syphilis  since  its  birth  ; 
and  I  do  not  make  out  from  the  report  that  the  child  was  examined 
medically  before  it  was  seven  months  old,  although  at  the  age  of  a 
month  and  a  half  it  is  alleged  to  have  been  icteroid  and  to  have  had 
blennorrhagic  conjunctivitis  ;  therefore  the  case  loses  its  value. 

In  this  question  of  the  inheritance  of  syphilis  comes  up  naturally 
a  consideration  of  syphilitic  placenta  (Fraeukel  f),  whether  the  latter 
allows  the  poison  to  pass  through,  and  many  other  interesting  ques- 
tions, mainly  theoretical.  In  a  treatise  like  the  present,  such  dis- 
cussions are  out  of  place.  Suffice  it  to  say,  gumma  of  the  placenta 
does  occur,  and  degeneration  of  the  blood-vessels  of  that  structure. 

Inheritance  in  the  Second  Generation. — Bearing  upon  this  question 
I  have  only  one  well-observed  case — a  girl  witli  inherited  disease  and 
syphilitic  mother,  both  of  whom  I  attended  for  many  years.  The 
child  had  the  characteristic  teeth,  eruptions  through  childhood,  gum- 
raata  at  the  developmental  period,  then  rather  severe  cerebral  syphilis 
with  prolonged  ocular  troubles.  Her  symptoms  were  pronounced 
and  varied,  and  all  got  well  under  large  doses  of  the  iodide  of  potas- 
sium. She  married  and  continued  to  suffer  from  cerebral  syphilis  in 
relapses  from  time  to  time  for  several  years,  when  she  died  of  another 

*  "Archives  of  Dermat.,"  July,  1880,  p.  314. 

t  "Uebcr  Placentarsyphilis,"  "  Archlv  f.  Gynjekologic,"  1873,  Bd.  v.  p.  1. 


METHODS   OF   CONTAGION.  515 

malady.  Iler  child  was  f;it  and  healthy,  and,  although  living  in  dirt, 
poverty,  and  neglect,  and  siiowing  eczcmatous  eruptions  and  boils  in 
the  hot  weather,  never  had  any  symptom  which  could  justify  a  sus- 
picion of  syphilis. 

In  the  discussion  on  syphilis  before  the  London  Pathological  Soci- 
ety *  in  1876,  Mr.  Simon  brought  forward  a  very  suggestive  case  of  a 
lady  whose  father  was  syphilitic,  and  who  had  a  child  with  symptoms 
considered  syphilitic.  Hutchinson  f  believes  ho  has  seen  a  case — but 
acquired  syphilis  could  not  be  positively  excluded.  Atkinson, J  of 
Baltimore,  published  what  seems  more  nearly  a  conclusive  case  than 
any  I  can  find,  but  here,  as  in  other  exceptional  phenomena,  great 
care  must  be  exercised  in  drawing  conclusions.  Generalizations  are 
dangerous  in  any  case  even  from  a  great  number  of  instances,  much 
more  so  when  the  number  is  small. 

Hill  and  Cooper  *  have  collated  a  number  of  cases  of  twin  births 
from  syphilitic  parents,  showing  that  in  such  cases  the  two  children 
may  suffer  unequally — one  dead,  the  other  lightly  affected  ;  or  both  born 
alive  and  having  the  disease  with  differing  intensity  ;  or  one  dead,  the 
other  apparently  perfectly  healthy,  but  in  a  few  weeks  showing  seri- 
ous (even  fatal)  symptoms  ;  or  one  child  suffering  severely,  the  other 
apparently  well — but  the  reporter  does  not  say  how  long  the  child  re- 
mained well. 

Chancre  is  produced  wherever  upon  the  body  of  an  unprotected 
person  the  syphilitic  virus  is  brought  in  contact  with  an  abraded  sur- 
face. That  it  may  make  for  itself  a  way  through  the  tender  epithe- 
lium of  mucous  membrane,  if  left  long  enough  in  contact  with  it,  as 
does  the  poison  of  chancroid,  has  not  been  proved,  but,  from  certain 
cases,  seems  highly  probable.  It  can  not  get  in  through  the  epithe- 
lium of  the  skin  without  an  abrasion  of  the  latter. 

The  methods  of  contagion  are  immediate  and  mediate.  The  latter 
method  is  much  more  common  for  syi^hilis  than  for  chancroid,  owing 
to  the  numerous  lesions  of  all  parts  of  the  body  capable  of  secreting 
the  poison,  their  long  duration,  and  apparent  insignificance.  Hence 
syphilis  is  very  often  transmitted  by  means  other  than  sexual  contact. 
Surgeons  and  accoucheurs  get  chancre  of  the  fingers  by  inoculating 
abraded  s]")ots  in  the  exercise  of  their  professional  duties,  and  in  their 
turn  may  spread  the  disease.  A  midwife,  ||  with  a  syphilitic  lesion 
upon  her  finger  of  which  she  was  aware,  communicated  the  disease 
directly  and  indirectly  to  forty-five  persons.  She  was  cojivieted  and 
sentenced  to  twelve  months'  hard  labor.  Chancre  is  not  infrequently 
transmitted  in  kissing,  a  little  mucous  patch  in  the  mouth  of  one 

*  Vol.  xxvii,  p.  421. 

f  "Lond.  Hosp.  Reports,"  vol.  ii,  p.  154. 

X  "Archives  of  Dermatology,"  January,  1877,  p.  106. 

*  Op.  cit.,  p.  64.  II  "Brit.  Med.  Journ.,"  February  17,  1883,  p.  335. 


51G  SYPHILIS. 

party  poisoning  anv  fissnro  on  tiie  lips  of  the  other  with  which  it  may 
come  in  contact.     Both  of  these  methods  are  immediate. 

Chiklren  acijuire  chancre  of  the  lips  from  nursing-women  with  mu- 
cous patches  of  the  nipple,  and,  on  the  other  hand,  healthy  nurses  get 
chancre  of  the  nipple  by  suckling  children  with  inherited  S3'philis  who 
have  mucous  patches  of  the  lips.  In  this  way  nurses  have  been  ac- 
cused of  giving  syphilis  to  their  nurslings,  when  the  truth  was  that 
they  (the  nurses)  received  the  disease  from  the  children.  Colles's  law, 
that  a  child  with  mucous  patches  of  the  mouth  can  not  produce  ulcer- 
ation of  the  nipple  if  it  sucks  its  mother,  depends  sim])ly  upon  the 
fact  that  its  mother  already  has  syphilis  before  tlie  child  is  born,  and 
consequently  can  not  get  a  new  chancre  of  the  nipple. 

Many  interesting  examples  of  mediate  contagion  have  been  re- 
corded. Puche  speaks  of  a  gentleman  with  a  long  prepuce,  who,  after 
marriage,  encountered  an  old  mistress,  with  whom  he  had  intercourse. 
Returning  home  shortly,  without  having  washed,  he  repeated  sexual 
intercourse  with  his  wife,  depositing  the  virus  from  his  prepuce  in  her 
vagina,  lie  escaped,  but,  in  due  course,  she  developed  chancre  and 
general  syphilis. 

A  similar  authentic  instance  is  related  of  a  woman  who  proved  un- 
faithful. Her  husband,  embracing  her  shortly  afterward,  relieved  her 
of  tlie  poison  left  in  her  vagina  by  her  lover,  himself  developed  chancre, 
while  she  escaped. 

Smokers  of  a  pipe  sometimes  get  chancre  of  the  lips,  the  virus  being 
deposited  upon  the  mouth-piece  of  the  pipe  by  some  previous  smoker 
who  had  mucous  patches  of  the  lip.  Toys  may  communicate  the  dis- 
ease to  a  child;  tooth-brushes,  even  cigars,  to  an  adult.  These  and  many 
other  objects  have  been  the  recorded  means  of  mediate  contagion. 

Glass-blowers  get  syphilis  in  the  same  manner,  as  they  work  in  sets 
of  three  at  tlie  same  tube,  passing  it  from  month  to  mouth.  Syphilis 
sometimes  runs  through  a  whole  family,  from  the  use  of  the  same 
spoons  or  cups,  passed  from  one  mouth  to  another.  Washer-women 
become  infected  in  cracks  of  the  fingers  through  the  virus  contained 
upon  soiled  clothes.  Wet-cups  *  once  started  an  endemo-epidemic  of 
syphilis.  Transplanting  teeth  has  proved  another  source  of  mediate 
contagion,  catheterization  of  the  Eustachian  tube  has  done  the  same. 
Hardy  f  records  that  in  1876  an  ear  specialist  in  Paris  inoculated 
thirty  to  forty  persons  with  a  Eustachian  catheter.  He  (Hardy)  had 
treated  five  of  these.  The  disease  has  been  communicated  by  the 
operation  of  circumcision,  with  instruments  which  were  infected  with 
syphilitic  virus,  and,  in  the  religious  rite,  possibly  though  not  prob- 
ably, by  the  act  of  sucking  the  wound.  J     Vaccination  is  a  familiar  in- 

*  Rollct,  p.  620.  +  -'  Gaz.  dcs  n6p.,"  September  10,  181S,  p.  833. 

X  K.  W.  Taylor  has  written  an  excellent  essay  on  tbis  subject,  "  N.  Y.  Med.  Jour.," 
December,  1873. 


DURATION   OF   CHANCRE.  517 

stance  of  mcclicite  contagion.  In  ull  sucli  cases  chancre  precedes  the 
development  of  general  syphilis. 

Duration  of  Syptiilitio  Chancre. — The  duration  of  sypliilitic 
chancre  is  from  two  weeks  to  several  months.  In  about  fifty  per  cent, 
of  the  cases  a  general  syphilitic  eruption  appears  before  the  chancre 
has  cicatrized.  A  chancre  once  healed  occasionally  rcindurates  and 
renlcerates. 

Number. — Syphilitic  chancre  is  most  often  unique,  because  com- 
monly only  one  point  is  inoculated.  It  may  be  multiple  to  any  extent, 
according  to  the  number  of  points  deprived  of  epithelium  and  capable 
of  absorption  which  are  primarily  exposed  to  infection.*  When  mul- 
tiple, however,  it  is  usually  so  from  the  first  and  not  consecutively, 
like  chancroid,  because  its  secretion  is  not  auto-inoculable. 

Size. — Syphilitic  chancre  may  occasionally  reach  a  large  size,  as 
large  as  a  quarter  or  half  dollar.  This  is,  however,  exceedingly  rare  ; 
commonly  it  does  not  grow  to  the  size  of  a  nickel  penny  ;  it  is  often 
as  small  as  a  split  pea  and  sometimes  smaller.  In  size  and  general 
appearance  it  compares  unfavorably  with  its  more  formidable-looking 
rival,  chancroid. 

Situation. — Syphilitic  chancre  occurs  indifferently  on  all  points 
of  the  body.  No  regions  are  exempt  from  it,  or  even  less  liable,  as  is 
the  case  with  chancroid.  Syphilitic  chancres  of  the  head,  face,  and 
breast  are  not  very  uncommon.  They  reach  their  full  size  and  devel- 
opment. Indeed,  chancre  of  the  lip  is  particularly  prominent,  large, 
hard  (spherical),  and  chronic  in  its  course.  The  genitals,  of  course, 
furnish  the  favorite  seat,  but  simply  because  they  are  most  often 
exposed.  The  favorite  position  on  the  penis  seems  to  be  the  mucous 
layer  of  the  prepuce,  often  just  behind  the  corona  glandis.  Urethral 
chancre  is  not  very  uncommon.  A  well-marked  case  is  reported  in 
the  "  American  Journal  of  Syphilography  and  Dermatolology,"  f  of  a 
patient  who  was  treated  for  gonorrhoea,  his  symptoms  being  creamy  dis- 
charge from  the  urethra,  with  pain  on  urination.  After  a  while  he 
developed  a  general  syphilitic  eruption,  and  enlarged,  indolent,  painless 
ganglia  were  felt  in  the  groins.  An  endoscopic  tube  was  now  intro- 
duced, and  detected  on  the  roof  of  the  urethra,  one  and  a  quarter  inch 
from  the  meatus,  the  chancre,  as  a  slight  oval  ulceration,  not  yet 
healed.  There  was  no  lumpiness  around  the  urethra,  no  painful  spot 
on  erection,  no  blood  in  the  urethral  discharge,  but  undoubtedly  the 
case  was  one  of  urethral  chancre  ;  for  gonorrhoea  does  not  produce 
ulceration  of  the  urethra.    The  endoscopic  tube  introduced  long  after- 

*  During  the  past  year  a  gentleman  under  the  author's  care  acquired  syphilis  through 
multiple  points  of  contagion,  and  had  eight  simultaneous  chancres,  all  of  about  four  weeks' 
incubation.  I  have  seen  another  case  of  multiple  chancre  on  the  nipple,  eight  on  one 
side,  four  on  the  other.   Fournier  has  a  case  of  seven  on  one  nipple,  sixteen  on  the  other. 

f  18V1,  page  3Y— Keyes. 


51S  SYPHILIS. 

ward  disclosed  a  faint  whitened  cicatrix,  marking  the  position  of  the 
old  ulcer  on  the  roof  of  the  canal.  These  appearances  were  veriiied 
by  several  gentlemen.  Another  (unpublished)  case  has  been  observed 
by  the  author.  Chancre  of  the  skin  around  the  genitals  and  anus  is 
not  very  uncommon.  In  the  female,  vaginal  chancre  seems  to  be  rare. 
Fournier,  out  of  249,  saw  only  one  in  the  vagina.  Binet,  *  in  128  of 
the  female  genitals,  found  only  two  in  the  vagina,  and  states  that  no 
others  have  reported  the  lesion  save  himself  and  Fournier.  Cervical 
chancre  is  not  uncomnn)n.  liusamon  f  saw  thirteen  in  1,374  venereal 
sores  upon  and  about  the  genitals  of  prostitutes  in  Moscow.  Chancre 
in  the  mouth  occurs  notably  upon  the  tonsil.  J 

Form  of  Syphilitic  Chancre. — Syphilitic  chancre  appears  after 
an  incubation  of  not  less  than  ten  da3's,  usually  not  till  the  end  of 
three  weeks,  as  a  reddened  spot,  which  quickly  excoriates  ;  or  as  an 
elevated  solid  papule,  which  excoriates  or  ulcerates.  It  may  take  any 
one  of  four  forms,  in  the  following  order  of  frequency  : 

(1)  Erosion  ; 

(2)  Ulceration  ; 

(3)  Deep  ulceration,  funnel-shaped  (Huntcriau  chancre)  ; 

(4)  Indurated  papule,  which  remains  dvj. 

Other  varieties,  such  as  the  herpetiform  chancre  of  Dubuc,  the  mucous 
tubercle  of  the  skin,  the  small  silvery  spot  looking  like  lichen  planus 
(Taylor  *),  the  ulcerated  fissure  at  the  nipple,  the  diphtheroid  chancre 
(Morrow,  ||  Taylor),  are  all  exceptions  so  rare  that  tlicy  do  not  call  for 
classification — their  simjile  mention  identifies  them. 

(1)  Erosion. — This  form  is  believed  to  include  two  thirds  of  all 
syphilitic  chancres.  Bassereau  put  it  at  three  quarters.  Its  favorite 
seat  is  mucous  membrane.  It  is  very  common  inside  of  the  prepuce. 
It  is  oval  or  a  little  irregular  in  shape,  with  a  polished,  raw-looking  sur- 
face of  a  vinous  red,  sometimes  very  dark  from  extravasation  of  blood  or 
from  jDigmentation,  or  of  a  more  subdued  gray  color  ;  occasionally 
there  is  a  central  adherent  pultaceous  membrane  (Clcrc),  but  usually 
the  only  discharge  is  a  sanious  serum,  and  that  scanty  ;  no  pus  being 
visible  whatever.  This  is  indeed  an  erosion,  and  not  an  ulcer.  The 
induration  of  this  form  is  most  often  parchment-like,  as  if  the  erosion 
reposed  upon  a  thin  sheet  of  parchment  slipped  beneath  it.  The  in- 
duration is  sometimes  central,  occasionally  annular.  These  erosions 
are  flat.  Sometimes  an  erosion  may  cap  an  enormous  induration  as 
large  as  a  marble,  as  on  the  lip,  and  not  be  attended  by  an  a}ipreciable 
discharge  of  pus.     The  surface  of  these  elevated,  indurated  erosions 

*  "  La  France  Med.,"  1881,  p.  38. 

f  "  Vicrteljahreschrift  fiir  Derm.  u.  Sypli.,"  vii,  1880,  p.  517. 

X  R.  W.  Taylor,  "N.  Y.  Med.  Jour.,"  May  24,  1884,  p.  577. 

«  "  Medical  News,"  September  8,  1883,  p.  277. 

I!  "  Venereal  Memoranda,"  New  York,  1886. 


FORM   OF   CHANCRE.  519 

sometimes  granulates,  becoming  papular.      Large  flat  erosions  may 
occupy  the  skin,  but  they  usually  scab. 

(2)  Ulceration. — Superficial  ulceration  with  slanting  edges  is  found 
with  parchment,  but  more  commonly  with  the  split-pea,  induration. 
The  ulcer  may  be  quite  superficial  if  the  induration  stand  out  x>romi- 
neutly,  or  the  induration  itself  may  be  excavated,  when  the  ulcer  will 
be  deep.  The  base  is  often  grayish,  discharging  a  slight  amount  of 
sero-purulent  fluid. 

(3)  Hunterian  Chancre. — This  form  is  less  common  than  either  of 
the  above,  but  is  actually  an  advanced  condition  of  the  last  variety. 
The  induration  is  often  extensive,  far  overreaching  the  edges  of  the 
ulcer,  which  latter  seems  to  have  eaten  down  into  it.  The  induration 
is  the  specific,  cartilaginous,  elastic,  woody  induration  of  syphilis. 
The  ulcer  has  sloping,  adherent  edges,  never  undermined,  not  the 
abrupt  borders  of  chancroid,  and.  the  funnel-shaped  appearance  of  the 
ulceration  is  not  found  in  any  other  variety  of  sore.  The  shape  is 
rounded  or  oval.  The  discharge  is  similar  to  that  of  the  last-described 
ulcer. 

(4)  Indurated  papule  loliicli  does  not  ulcerate  is  found  sometimes 
on  the  skin  after  inoculation,  natural  or  artificial,  and  occasionally  on 
the  penis,  even  on  the  mucous  layer  of  the  prepuce  in  patients  whose 
prepuce  is  loose,  short,  and  dry.  These  indurated  tubercles  would 
undoubtedly  excoriate  or  ulcerate  if  kept  moist,  and  in  fact  the  elevated 
excoriated  chancre  often  remains  for  weeks  as  an  induration  before  the 
surface  erosion  apj)ears.  Indurated  pajpules  of  the  skin,  which  do  not 
erode  or  ulcerate,  scale  off  after  a  time,  or  become  covered  with  a  scaly 
crust.     The  color  of  these  papules  is  a  dark  vinous  red. 

Under  any  of  the  above  forms  may  uncomplicated  syphilitic  chancre 
api3ear.  The  course  is  about  the  same  in  all.  They  rarely  heal  within 
two  weeks,  and  often  last  for  months.  There  is  rarely  more  than  one 
of  them,  and,  if  two  or  more  coexist,  they  are  usually  of  the  same  type. 
The  induration,  which  generally  may  be  found  from  the  first,  occa- 
sionally does  not  appear  until  after  some  days.  It  may  disa23pear  within 
a  fortnight,  but  usually  outlasts  the  sore,  even  remaining  behind  in 
the  cicatrix.     Chancre  uninflamed  and  unirritated  is  painless. 

The  symptoms  of  urethral  chancre,  which  can  not  be  seen,  are 
usually  a  discharge  coming  on  long  after  suspicious  connection,  gener- 
ally thin,  often  bloody,  a  painful  spot  along  the  urethra  during  erec- 
tion, and  a  lumpiness  felt  through  the  skin ;  but  all  these  signs  are 
sometimes  lacking  except  the  discharge,  and  even  tliis  may  be  quite 
creamy.  The  endoscopic  tube  may  be  used  in  certain  cases,  making 
an  absolute  diagnosis  of  ulcer,  and  the  condition  of  the  inguinal  glands 
goes  largely  to  clear  up  its  nature.  Urethral  chancre  is  more  often 
situated  just  within  the  meatus,  and  may  be  seen  by  separating  the 
lips  of  the  latter. 


520  SYPHILIS. 

Course  of  Chaistcre. — Syphilitic  chancre  progresses  slowly,  reach- 
ing its  lieight  in  a  few  days  or  weeks,  and  then,  wilii  or  Avithout  a 
stationary  period,  repair  begins  by  a  change  in  color  of  the  sore,  which 
beconies  more  rosy,  the  induration  often  simultaneously  commencing 
to  abate.  Thicker  pus  forms  u])on  the  ulcer,  and  it  goes  on  to  cica- 
trization from  the  edges.  The  poison  of  the  secretion  remains  to  the 
end. 

COMPLICATIONS. 

The  complications  of  S3'philitic  chancre  are  :  (a)  vegetations  ;  (b) 
inflammation  ;  (c)  chancroid  (mixed  chancre) ;  (d)  transformation  into 
mucous  patch  ;  (c)  phagedena  and  gangrene  ;  (/)  syi)hilitic  bubo,  which 
is  indeed  not  a  complication,  but  a  necessary  accompaniment  of  syphi- 
litic chancre  ;  (r/)  lymphangitis. 

(«)  Vegetations. — AVarty  growths  are  liable  to  spring  up  around 
syphilitic  chancre  of  the  prepuce  or  anus,  as  they  are  with  other  forms 
of  irritative  disease  (chancroid,  balanitis,  gonorrhoea).  These  arc 
rare  and  purely  accidental.  Syphilis  as  a  poison  has  nothing  to  do 
with  their  production. 

(b)  IxFLAMMATiox  may  complicate  syphilitic  chancre,  from  posi- 
tion, meclianical  or  chemical  irritation,  etc.,  occasioning  pain,  and  a 
more  purulent  discharge,  which  latter  may  be  auto-inoculable,  produc- 
ing an  abortive  pustule,  or  a  small,  transient  ulcer,  and  liable  to  lead 
to  the  further  complication  of  suppurating  bubo, 

{c)  Chaxcroid  may  complicate  syphilitic  chancre,  the  two  sores 
existing  together  side  by  side,  each  with  its  own  peculiar  characters, 
or  the  same  spot  may  have  been  simultaneously  or  successively  inocu- 
lated by  the  two  poisons,  giving  rise  to  what  is  known  as  ''mixed 
chancre,"'  a  sore  which  possesses  the  characters  and  qualities  of  both 
of  these  lesions.  The  two  poisons  are  distinct,  and  run  their  own 
course,  each  unmodilied  by  the  other,  but,  if  both  develop  upon  the 
same  spot,  the  character  of  the  lesion  is  altered,  and  it  becomes  a 
mixed  sore.  When  a  syphilitic  chancre  is  inoculated  with  chancroid 
pus,  the  ulceration  rapidly  deepens  and  progresses,  putting  on  all  the 
characters  of  chancroid;  but  the  syphilitic  induration  remains.  On 
the  other  hand,  when  a  chancroid  is  inoculated  with  syphilitic  virus, 
the  ulcer  is  unmodified,  but,  after  a  proper  incubation,  syphilitic  in- 
duration sets  in.  These  facts,  which  have  been  proved  experiment- 
ally, have  been  also  verified  clinically  by  confrontation.  If  a  given 
abrasion  be  inoculated  with  both  poisons  in  sexual  intercourse,  the 
chancroid  develops  first,  and,  for  a  time,  nothing  but  a  chancroid  ex- 
ists, furnishing  auto-inoculable  and  hetero-inoculable  pus  producing 
chancroid  only,  and  not  syphilis.  After  a  certain  variable  incubation, 
however,  the  soft  sore  indurates  spontaneously,  and  then  the  chancre 
is  mixed,  capable  of  imparting  chancroid  alone  by  contact,  since  the 


COMPLICATIONS   OF   CHANCRE.  521 

chancroid  poison  is  more  virulent,  more  contagious,  than  the  syplii- 
litic  ;  or  mixed  chancre,  followed  by  general  syphilis.  Finally,  if  the 
period  of  incubation  of  the  syphilitic  virus  happens  to  be  very  long,  the 
chancroid  may  get  well,  or  be  cured  by  cauterization,  but  in  due  time 
the  syphilitic  chancre  appears  upon  the  same  spot,  and  then  hetero- 
inoculation  will  produce  only  the  syphilitic  chancre,  with  its  inevitable 
accompaniment,  general  syphilis.  The  literature  of  experimental  syphi- 
lis furnishes  some  very  striking  examples  of  mixed  chancre.  The  fol- 
lowing two  are  particularly  instructive  : 

Melchior  Robert  inoculated  a  student  with  the  secretion  of  a  mixed 
chancre.  A  classical  chancroid  followed,  the  pus  of  which  proved 
auto-inoculable.  After  the  ulcer,  the  result  of  inoculation  with  the 
mixed  poison,  had  nearly  healed,  induration  set  in,  the  sore  reulcerated, 
and  general  syphilis  followed. 

Lindwiirm  had  a  female  patient  with  multiiDle  chancroid.  Upon 
one  of  these  only  he  inoculated  the  secretion  of  a  syphilitic  chancre. 
ISTo  change  occurred.  The  patient  got  nearly  well,  and  left  the  hos- 
pital, but  eight  days  afterward  she  returned  ;  the  ulcer  which  had 
been  inoculated  had  broken  out  afresh,  and  had  indurated.  This  sore 
remained  open,  while  all  the  other  chancroids  got  well  and  remained 
well.     General  syphilis  followed. 

Mixed  chancre,  then,  is  a  reality,  and  does  exist  clinically.  Hence 
the  rule  :  Wherever  the  secretion  of  an  ulcer  possessed  of  specific  in- 
duration, and  followed  by  syphilis,  produces  by  auto-inoculation  a 
characteristic  chancroid  ulcer,  itself  auto-inoculable,  such  indurated 
ulcer  is  invariably  a  mixed  chancre. 

Mixed  chancre  is  liable  to  all  the  complications  which  may  affect 
either  form  of  ulcer,  even  virulent  bubo. 

The  methods  of  acquiring  mixed  chancre  clinically  are  self-evident. 
Both  poisons  may  enter  simultaneously  through  the  same  abrasion. 
An  individual  with  either  variety  of  sore  may  inoculate  himself,  dur- 
ing sexual  intercourse,  upon  the  same  spot  with  the  other  virus. 

{d)  Teansfoemation-  iistto  Mucous  Patch. — A  chancre,  which 
has  lasted  until  the  period  for  secondary  manifestations  has  come  on, 
may  granulate  upon  its  surface,  retain  or  lose  its  induration,  become 
covered  with  a  whitish  pellicle,  and,  in  short,  change  into  a  mucous 
patch.  This  change  has  been  critically  studied  by  Eicord,  Fournier, 
Deville,  Devasse,  and  others.  It  is  most  often  observed  upon  women  and 
children,  and  particularly  upon  thin  skin  and  mucous  membrane  where 
there  is  continual  moisture,  a  circumstance  greatly  favoring  the  change. 

(e)  Phagedejsta  and  G-angeeke. — Phagedena,  already  studied 
in  connection  with  chancroid,  may  also,  though  more  rarely,  compli- 
cate true  syphilitic  chancre.  The  form  most  usually  seen  is  the  gan- 
grenous. The  gangrene  may  involve  all  the  induration,  in  which  case 
the  latter  ceases  to  be  perceptible.     The  iDultaceous  and  serpiginous 


522  SYPHILIS. 

varieties  of  pliagedena  are  very  rarely  found  with  pure  syphilitic  chan- 
cre. Their  existence,  especially  the  latter,  •which  is  most  uncommon, 
makes  it  probable  that  the  chancre  was  originally  of  the  mixed  vari- 
ety. Sometimes  the  ulceration  outstrips  the  induration,  in  which 
case  the  latter  disappears  ;  rarely  both  advance  together.  In  four 
hundred  and  fourteen  cases  of  syphilitic  chancre,  Bassereau  found 
l^hagedena  in  sixt}'.  In  ninety-eight  cases,  Fournier  found  eleven  of 
phagedena.  A  healing  chancre  may  reulcerate  and  then  become 
phagedenic.  Bassercau,  Diday,  and  others  believe  that,  when  syphi- 
litic chancre  is  i)hagedenic,  the  tyi^e  of  the  general  syphilis  which  fol- 
lows is  severe. 

For  diagnosis  of  syphilitic  chancre,  see  Diagxostic  Table. 

Fro(/no^is. — If  the  chancre  is  syphilitic,  so  also  is  the  patient. 

For  (/)  syphilitic  bubo,  and  (g)  lym})hangitis,  see  below. 

Treat meni  of  Sijpliililic  Chancre. — No  amount  of  cauterization  nor 
any  local  treatment  can  prevent  the  development  of  general  syphilis 
after  the  poison  has  once  been  absorbed,  much  less  after  the  chancre 
has  appeared.  Cauterization  often  hastens  the  healing,  but  indura- 
tion is  liable  to  reap^Dear  and  to  reulcerate,  and  nothing  is  gained  to 
compensate  for  the  pain  of  the  ojieration.  General  syphilis  is  inevita- 
ble. At  the  present  day  the  plan  of  treatment  recently  revived  by 
Auspitz*  (who  reported  thirty-three  cases),  of  excision  of  the  jirimary 
lesion,  has  had  a  few  ardent  advocates,  and  a  fair  trial  at  the  hands  of 
many  operators.  It  had  been  tried  before  and  given  up.  Meyer,  in 
1840,  Hueter,t  in  18G7,  advocated  it;  Ulrich,  Coulson,  Langenbeck, 
Thiry,  Vogt  tried  it,  deciding  some  for,  some  against,  its  efficacy. 
In  1882  P.  A.  Morrow  +  wrote  a  full  resume  of  the  220  cases  then  re- 
ported from  all  sources,  with  sixty  alleged  cures,  and  decided  against 
the  treatment  from  the  mere  standpoint  of  weight  of  evidence.  Since 
that  time  much  has  been  written,  but  the  weigiit  of  evidence  has  been 
steadily  accumulating  against  the  value  of  the  measure,  until  now  at 
this  date,  though  still  practiced  considerably  in  Germany,  it  has  been 
abandoned  by  the  profession  of  the  world  at  large.  I  have  treated  a 
number  of  patients  from  whom  chancre  had  been  excised  at  the  hands 
of  others.  I  have  found  the  cases  both  light  and  severe,  as  the  ordinary 
run  is  in  those  who  have  let  their  chancres  alone.  I  do  not  believe 
the  excision  of  the  primary  lesion  has  the  least  possible  modifying 
effect  upon  the  development  of  subsequent  syphilis,  or  in  any  way 
moderates  its  intensity.  I  have  offered  excision  as  a  tentative  experi- 
ment to  many,  but,  as  I  could  not  promise  any  benefit,  my  offer  was 
always  declined,  except  in  one  instance  already  published.**     This  was 

*  "  Vrtljahresschrift  f.  Derm.  n.  Syph.,"  1877,  i  and  ii,  p.  lOL 
t  "Bed.  klin.  AYochcnschrift,"  No.  27,  1867. 

X  "Jour,  of  Cutaneous  and  Venereal  Diseases."  vol.  i,  Xo.  3,  December,  1882,  p.  65. 

*  "New  York  Medical  Journal,"  April  25,  1885,  p.  404. 


SYPHILITIC  BUBO.  523 

a  physician  who  came  with  a  small  dry  pimple  on  the  back  of  his  penis 
which  had  been  present  less  than  twenty-four  hours.  I  cut  it  out 
cleanly  with  considerable  surrounding  tissue.  It  healed  promptly  and 
never  reappeared,  nor  did  the  scar  indurate,  yet  the  patient  liad  a 
very  sharp  papular  syphilide  at  the  regular  time,  in  no  way  moderated 
by  his  attempted  abortive  treatment. 

The  best  local  treatment  consists  in  the  use  of  dry  lint,  or  any 
mild  astringent  lotion,  or,  perhaps  better,  sprinkling  with  iodoform, 
or  calomel,  or  the  use  of  black  or  yellow  wash.  The  sore  is  not  pain- 
ful, and  will  leave  less  of  a  scar  if  unmolested  than  if  irritated  and 
inflamed.  Mixed  sore  is  better  cauterized  to  destroy  the  chancroidal 
vii'us,  and  the  local  treatment  of  phagedena  is  the  same  as  already  set 
down  for  that  complication  attacking  chancroid.  There  is  one  im- 
portant difference,  however,  namely,  that  the  phagedena  attacking 
syphilitic  chancre  may  be  kept  up  by  the  general  debilitating  influence 
of  syphilis  u]3on  the  patient's  vitality,  and  consequently,  in  these  cases 
only,  the  antidote  to  that  influence,  mercury,  given  internally,  has, 
a  favorable  effect  in  retarding  the  progress  of  phagedena. 

Internal  treatment  of  syphilitic  chancre  is  the  same  as  that  of  early 
syphilis,  and  treatment  should  be  commenced  in  all  cases  when  the 
diagnosis  is  undoubted.  It  has  a  marked  beneficial  effect  upon  the 
duration  of  the  chancre.  Where  there  is  the  least  shadow  of  a  doubt, 
no  mercury  should  on  any  account  he  administered  until  an  eruption 
has  cleared  up  the  diagnosis. 

(/)  Syphilitic  Bubo. — The  term  "syphilitic  bubo"  has  been  ap- 
plied to  the  indolent  enlargement  and  induration  of  those  lymphatic 
glands  receiving  the  absorbents  from  a  syphilitic  chancre,  not  to  the 
other  glandular  enlargements  occurring  in  the  course  of  syphilis. 
Syphilitic  bubo  consequently  may  occur  in  many  different  situations, 
according  to  the  position  of  the  chancre.  It  is  usually  found  in  the 
groin,  because  syphilitic  chancre  more  often  occurs  on  or  around  the 
genitals  than  elsewhere.  Thus  the  inguinal  glands  are  affected  in 
chancre  of  the  penis,  urethra,  groin,  lower  part  of  abdomen,  scrotum, 
thighs,  perinasum,  buttocks,  anus,  or  rectum  ;  the  submaxillary  in 
chancre  of  the  lips  or  mouth,  the  preaural  in  chancre  of  the  face.  In 
like  manner  the  sub-hyoid,  post-cervical,  axillary,  epitrochlear,  or  other 
gland,  may  be  the  seat  of  syphilitic  bubo.  With  syphilitic  chancre  of 
the  genitals,  the  cluster  of  glands  in  the  groin  becomes  enlarged  and 
indurated,  not  a  single  gland  but  a  group,  which  group,  since  Ricord, 
has  become  classical  under  the  name  of  "pleiad."  The  pleiad  consists 
of  one  gland  larger  than  the  rest,  with  one  or  two  or  half  a  dozen 
smaller  glands,  nearly  all  equally  indurated  on  either  side.  The  indu- 
ration in  some  cases  is  not  very  strongly  marked.  The  glands  rarely 
become  very  large,  varying  from  the  size  of  a  pea  to  that  of  a  marble, 
and  they  retain  their  round  or  oval  shape.     They  are  freely  movable 


524  SYPHILIS. 

under  the  skin,  nsnally  each  distinct  from  the  others.  There  is  rarely 
any  pain  even  on  pressure,  thou^jh  slij2:ht  tenderness  may  exist  at  first. 
This  pleiad  of  indolent  indurated  glands  may  be  (direct)  unilateral,  on 
the  same  side  with  the  chancre  or  crossed,  or  (usually)  bilateral,  the 
glands  on  the  same  side  with  the  chancre  being  most  markedly  affected. 

This  induration  of  the  glands  exactly  reseniljles,  in  its  woody,  ivory- 
like feel,  the  induration  of  the  chancre,  but  in  some  cases  is  more  soft 
and  elastic,  like  cartilage  or  India-rubber.  The  induration  appears 
during  the  second  week  of  the  existence  of  chancre.  Fournicr  records, 
as  unique,  a  case  in  which  the  induration  of  the  ganglia  was  not  de- 
tected until  the  twentj'-sevcnth  day  after  the  appearance  of  chancre. 
Sometimes  instead  of  the  usual  pleiad  there  is  but  a  single  indurated 
gland,  perhaps  as  large  as  a  nut.  Another  variation  is  the  develop- 
ment of  a  single  enormous  syphilitic  bubo,  as  large  as  an  og:g,  on  one 
or  both  sides.  These  were  found  by  Bassereau  on  dissection  to  con- 
sist of  an  agglomeration  of  many  separate  glands  matted  together  by 
large  indurated  lymphatic  cords,  and  tough,  thickened  layers  of  con- 
nective tissue.  Occasionally  a  hardened  lynii)hatic  trunk  may  be 
traced  from  the  induration  of  the  chancre  to  the  indurated  glands. 
In  strumous  subjects  the  glands  are  apt  to  be  very  large,  and  to  be  due 
to  strumous  degeneration  as  well  as  specific  induration. 

Submaxillary  and  axillary  syphilitic  bubo  often  consists  of  one  very 
large,  hard  gland.  The  glands  constituting  syphilitic  bubo  usually 
reach  their  full  development  in  from  one  to  three  weeks.  They  then 
remain  stationary  for  several  Aveeks  or  months,  occasionally  for  over  a 
year.  They  are  habitually  present  when  the  first  general  erujitions 
appear,  and  may  at  this  time  undergo  a  sudden  increase  in  size  and 
induration.  Sometimes,  on  the  contrary,  without  known  cause,  the 
glands  speedily  return  to  their  natural  size,  and  all  induration  dis- 
appears. 

Suppuration  of  syphilitic  bubo  takes  place  so  rarely  that  it  may  be 
said  practically  never  to  occur.  But  the  syphilitic  as  well  as  the 
healthy  gland  is  subject  to  inflammation  from  injury,  friction,  or  from 
inflammation  of  the  chancre,  and  then  suppuration  may  come  on. 
Strumous  glands  also  may  degenerate,  mat  together,  and  slowly  sup- 
purate. AVhen  a  syphilitic  bubo  suppurates,  its  pus  is  never  auto- 
inoculable.  "With  suppuration,  there  is  of  course  pain  in  the  affected 
gland.  With  "  mixed  chancre,"  suppurating  bubo  is  not  uncommon, 
and  even  virulent  bubo  may  occur.  Fournicr  thinks  that  pus  once 
formed  in  a  syphilitic  bubo  is  more  capable  of  absorption  than  in  any 
other  form  of  bubo.  Syphilitic  bubo  bears  no  relation  to  the  number 
or  size  of  the  chancres.  Large  buboes  often  become  adherent  to  the 
skin.  In  three  hundred  and  sixty-eight  cases  of  syphilitic  bubo,  Basse- 
reau saw  suppuration  in  five  per  cent.  Syphilitic  bubo  is  so  constant 
an  accompaniment  of  syphilitic  chancre  that  practically  it  may  be 


SYPHILITIC   LYMPHANGITIS.  525 

said  to  occur  invariably.  Fournier,  in  analyzing  two  hundred  and 
sixty-five  cases  of  sypliilitic  chancre,  found  ganglionic  induration 
absent  in  five.  Two  of  the  individuals  were  very  fat,  and  possiljly  the 
ganglia  existed,  but  could  not  be  found.  The  causes  of  the  absence 
of  induration  in  the  glands  are  believed  to  be  occasionally  phagedena 
of  the  chancre  (Fournier),  or  the  excessive  smallness  of  the  lymphatic 
glands  in  some  fat  people  (Ricord)  ;  finally,  in  those  rare  cases  where 
indurated  chancre  occurs  a  second  time  in  patients  who  have  had 
syphilis,  the  glands  may  not  indurate.  Syphilitic,  spontaneous  bubo 
{bubon  (TembUe)  does  not  exist.  For  diagnosis  of  syphilitic  biibo,  see 
Diagnostic  Table. 

Treatment. — The  treatment  of  syphilitic  buboes  is  that  of  early 
syphilis,  but  treatment  has  indeed  little  or  no  effect  upon  them,  as 
they  often  persist  long  after  the  early  cutaneous  eruption  has  disap- 
peared under  treatment.  Inflammation  and  strumous  complications 
are  to  be  met  appropriately. 

{g)  Syphilitic  Lymphangitis  is  a  specific  induration  of  the 
lymph-vessels  and  surrounding  cellular  tissue.  Hard,  smooth,  and 
knotty  cords  are  percejjtible  under  the  skin  of  the  penis,  feeling  like 
the  vas  deferens,  varying  from  the  size  of  a  knitting-needle  to  that  of 
a  goose-quill.  They  are  insensitive  to  pressure,  and  the  skin  over  them 
is  not  red.  Starting  in  the  induration  of  the  chancre,  they  often  do 
not  reach  to  the  root  of  the  jDcnis,  but  may  extend  to  the  ganglia. 
Sometimes,  but  rarely,  the  surrounding  induration  includes  the  blood- 
vessels. There  may  be  one  or  more  of  these  cords  on  one  or  both  sides 
of  the  penis.  Lymphangitis,  when  present,  generally  precedes  adenitis, 
coming  on  shortly  after  the  induration  of  the  chancre.  It  melts  aivay 
usually  during  the  disappearance  of  chancrous  induration,  lasting  from 
three  weeks  to  six  months,  and  more.  Earely  inflammation  or  suppu- 
ration may  occur,  but  the  pus  is  never  auto-inoculable.  If  the  chan- 
cre be  mixed,  so  may  be  the  lymphangitis.  Eollet  states  that  syphi- 
litic lymphangitis  occurs  in  about  twenty  per  cent  of  cases.  Xo  spe- 
cial treatment  is  necessary,  except  what  may  be  required  for  inflam- 
matory complications. 


52(3 


SYPUILIS. 


CHAPTER  ly. 


SYPHILIS. 

Diagnostic  Tabic  of  Sypliilitic  Cliancrc.  Chancroid,  Herpes,  and  Ulcerated  Abrasion.— Of  Syphilitic 
Bubo  and  the  Bubo  of  Chancroid.— Of  Syphilitic  Lymphangitis,  and  tlie  I,ynii)linngiiis  of  Chan- 
croid.—General  Syphilis.— Secondary,  Tertiary,  :Malignant,  Irregular,  and  Intenncdiary  Syph- 
ilides.— Prognosis  of  Syphilis.— Duration.— lulUience  of  Gout  and  Scrofula  upon  the  Course  of 
Syphilis.— The  Ten  General  Characteristics  of  Syphilides.- Concomitant  Symptoms  of  Sec- 
ondary Syphilis.— Secondary  Incubation,  Syphilitic  Fever,  Alopecia,  Indolent  Glandular  En- 
gorgement, Sore  Throat,  Analgesia. 

The  following  table  is  intended  to  serve  as  a  summary  of  the  broad, 
classical  characteristics  of  syphilitic  chancre  and  chancroid,  with  their 
accompanying  buboes,  as  well  as  for  the  differential  diagnosis  of  syphi- 
litic chancre,  chancroid,  herpes,  and  ulcerated  abrasions ;  of  the  bubo 
of  chancroid,  and  that  of  syphilis ;  and  of  the  different  forms  of 
lymphangitis. 

Ulcerated   {Balaniiic 
or  other)  Abrasion. 


Syphilitic  Chancre. 

1.  Nature.  —  Al- 
ways a  constitutional 
affection. 

2.  Cause.  —  Sexu- 
al intercourse  with 
a  patient  suffering 
from  syphilitic  chan- 
cre, or  some  second- 
ary syphilitic  lesion 
of  or  near  the  geni- 
tals, vaccination  with 
syphilitic  blood,  ac- 
cidental or  designed 
inoculation  of  any 
vehicle  containing 
the  syphilitic  virus 
upon  an  abrasion 
of  any  portion  of  any 
tegumentary  expan- 
sion. 

3.  Situation.  — 
Usually  upon  or  near 
the  genitals,  not  very 
infrequent  on  the 
head,  hands,  or  nip- 
ple. 

4.  Incubation.  — 
Constant,    not    less 


CJiancroid. 
Always  a  local 


disease. 

2.  Sexual  inter- 
course with  a  patient 
suffering  from  chan- 
croid of  or  near  the 
genitals ;  accidental 
or  designed  inocula- 
tion with  the  secre- 
tion of  chancroid,  or 
that  of  virulent  bu- 
bo. 


Herpes. 

1 .  Sometimes  a 
local  disease,  some- 
times a  neurosis. 

2.  Mechanical  ir- 
ritation, friction,  as 
in  sexual  intercourse ; 
chemical  irritation, 
as  of  acrid  dis- 
charges. As  a  se- 
quence of  cold,  fever, 
or  as  an  essential 
neurosis. 


1.    Always    local. 


2.  All  of  the 
causes  mentioned  for 
herpes,  except  the 
last  three. 


3.  Very  rarely 
encountered  except 
on  or  around  the 
genitals. 


4.  None  after  ab- 
sorption of  the  poi- 


3.  Of  very  fre- 
quent occurrence  up- 
on the  genitals. 


4.  None. 


3.  Same. 


4.  None. 


DIAGNOSTIC  TABLE. 


527 


Syphililic  Chancre. 

than  ten  days,  usu- 
ally three  weeks. 


5.  Commencement. 
— Begins  as  an  ero- 
sion or  a  papule, 
and  remains  an  ero- 
sion or  ulcerates. 

6.  Number. — Usu- 
ally unique  or  simul- 
taneously multiple ; 
never  multiple  by 
successive  auto-inoc- 
ulation ;  never  con- 
fluent. 

v.  Physiognom>/. — 
(a)  Shape :  round, 
oval,  or  symmetri- 
cally irregular. 


(h)  Lesion  is  ha- 
bitually flat,  capped 
by  erosion  or  super- 
ficial ulceration ;  or 
scooped  out ;  or  deep, 
funnel-shaped  ulcer, 
with  sloping  edges. 
Sometimes  the  pap- 
ule is  dry  and  scaly. 


(e)  Edges :  slop- 
ing and  adherent, 
sometimes  promi- 
nently  elevated. 

{d)         Bottom : 
smooth,  shining. 

(e)  Color:  somber, 
darkish    red,    gray, 


Chancroid. 

son.  Ulcer  usually 
fully  formed  on  the 
second  or  third  day  ; 
very  rarely  com- 
mences later  than 
the  seventh. 

5.  Begins  as  a 
pustule  or  ulcer,  and 
invaiiably  remains 
as  an  ulcer. 

6.  Usually  mul- 
tiple, both  simulta- 
neously and  by  suc- 
cessive auto-inocula- 
tion ;  often  conflu- 
ent. 

Y.  («)  Shape : 
round,  oval,  or  un- 
symmetrically  irreg- 
ular, with  border  de- 
scribed by  segments 
of  large  circles. 

(5)  Always  true 
ulcer,  excavated,  hol- 
lowed out. 


Herpes. 


Ulcerated  (Jialanitie 
or  other)  AOrcmion, 


(c)  Edges :  sharp- 
ly cut,  abrupt,  often 
undermined. 

(d)  Bottom :  un- 
even, warty,  irregu- 
lar, without  luster. 

(e)  Color :  yel- 
low,    tawny,     false- 


5.  Begins  as  a 
group  of  vesicles, 
rarely  as  a  single 
vesicle,  and  remains 
as  an  ulcer. 

6.  Generally  mul- 
tiple, simultaneously 
and  by  successive 
crops  of  vesicles ; 
sometimes  confluent. 


V.  (a)  Shape :  irreg- 
ularly rounded,  with 
borders  described  by 
segments  of  small 
circles  left  by  the 
different  vesicles. 

(6)  Ulcer  usually 
superficial  ;  some- 
times in  solitary  her- 
pes there  is  but  one 
vesicle,  and  the  ul- 
cer is  absolutely  cir- 
cular (Fournier) ;  in 
this  case  there  are  no 
neighboring  patches 
of  vesicles  to  clear 
up  diagnosis.  The 
base  and  general 
physiognomy  of  her- 
petic ulceration  are, 
in  other  respects, 
similar  to  those  of 
chancroid,  but  of 
less  virulent  aspect. 


5.  Begins  as  an 
abrasion  or  fissure, 
and  remains  as  an 
ulceration. 

6.  Generally  mul- 
tiple and  confluent. 


7.  Irregular,  of 
any  shape,  otherwise 
resembling  superfi- 
cial chancroid  ulcer. 


528 


SYPHILIS. 


Suphilitie  Chancre. 

or  black,  lesion  some- 
times livid  and  scaly, 
occasionally  scabbed. 

(/)  Sei-iction : 
slight,  scro-sanguino- 
lent,  unless  irritation 
provokes  infianinia- 
tion  and  a  supply  of 
pus. 

8.  History. —  Not 
found  on  patients 
who  have  had  syphi- 
lis previously. 


Chancroid. 

membranous  -  look- 
ing, sometimes 
bright. 

(/)  Secretion: 
abundant  and  puru- 
lent. 


S.  Found  indifTer- 
cntly  upon  all. 


Herpes. 


Ulcerated   {Balanitic 
or  other)  Abrasion. 


9.  Inocuhhility. 
—  Not  auto  -  inocu- 
lable  without  great 
difiBculty,  unless  irri- 
tated, and  secrctiug 
thick  pus. 


9.  Readily  auto- 
iuoculablo,  produc- 
ing characteristic 
chancroid  ulcer  by 
the  third  day. 


Course.  —        10.    Rapidly    pro- 
progressive,     gressive,      cicatriza- 


10. 
Slowly 
cicatrization  slow. 


11.  Srnsihilifl/.— 
Rarely  painful. 

12.  Induration. — 
Constant,  parchment- 
like, and  very  faint, 
or  cartilaginous  and 
extensive,  terminat- 
ing abrupth',  not 
shading  off  into  parts 
around,  almost  in- 
sensitive to  pressure, 
movable  upon  parts 
beneath  the  skin,  and 
not  adherent  to  the 


tion  slow. 


11.  Often  pain- 
ful. 

12.  Absent  in 
typical  cases.  An 
induration  may  be 
caused  by  irrit.ints 
or  by  inflammation. 
It  is  boggy,  not  clas- 
tic, sensitive  to  press- 
ure, shades  off  into 
surrounding  tissues, 
is  adherent  to  parts 
around,  disappears 
promptly  on  healing 


8.  Found  by  pref- 
erence ui)on  patients 
with  long  prepuce 
and  tender  balano- 
prcputial  mucous 
membrane,  often 
showing  marked  ten- 
dency to  return 
monthly,  fortnightly, 
or  at  irregular  inter- 
vals after  lack  of 
cleanliness,  a  ca- 
rouse, or  unusual 
sexual  intercourse. 

9.  Sometimes  au- 
to -  iuoculable  wiih 
great  difficulty,  when 
secreting  thick  pus, 
producing  abortive 
pustule,  not  charac- 
teristic chancroid  ul- 
cer. 

10.  Docs  not  usu- 
ally tend  to  get  much 
larger  than  the  size 
at  which  it  started; 
limitation  and  cica- 
trization rapid. 

11.  Stinging  heat 
at  commencement. 

12.  Inflammatory 
induration,  capable 
of  being  produced  by 
the  same  causes  as 
in  chancroid,  and  be- 
having in  a  precise- 
ly similar  manner. 


8.  Found  indiffer- 
ently upon  all  on  the 
action  of  efficient 
causes.  Most  com- 
mon on  patients  with 
long,  tight  prepuce, 
who  are  not  cleanly 
in  their  habits. 


9.  Same. 


10.  Same. 


11.  Usually  pain- 
ful. 

12.  Same. 


DIAGNOSTIC   TABLE. 


529 


Syphilitic  Chancre. 

latter.  Induration 
may  disappear  in  a 
few  days,  usually  out- 
lasts the  sore,  and 
may  remain  for  years 
in  the  cicatrix. 

13.  Transmission 
to  Animals.  —  Not 
transmissible. 

14.  Phagedena. — 
May  occur  rarely. 

15.  Bubo. — Syplii- 
litic  bubo  constant. 


16.  Lymphangitis. 
—  Syphilitic  lym- 
phangitis possible. 

lY.  Prognosis.  — 
For  local  conse- 
quences good,  but 
syphilis  follows. 

1 8.  Treatment.  — 
Local  treatment  but 
slightly  effective. 


Chancroid. 

of  the  sore,  or  before 
that  time. 


13.  Transmissible 
with  difficulty. 

14.  Much  more 
common. 

15.  In  about  two 
thirds  of  cases  glands 
are  unaffected,  in  the 
other  third  inflamma- 
tory or  virulent  bubo 
occurs. 

16.  Inflammatory 
or  virulent  lymphan- 
gitis possible. 

17.  For  local  con- 
sequences more  se- 
rious ;  no  after-effect. 

18.  Local  treat- 
ment curative. 


Herpes. 


Ulcerated  [Balanilic 
or  other)  Abrasion. 


Syphilitic  Bubo. 

1.  Nature. — It  is  a  specific  affection,  with 
peculiar  characteristics. 

2.  Frequency. — It  is  a  constant  symp- 
tom attending  syphilitic  chancre. 

3.  Number  of  Glands  involved. — In  those 
regions  where  multiple  glands  are  found,  it 
is  generally  poly-ganglionic ;  these  may  be 
unilateral  or  bilateral  in  the  groin,  rarely 
matted  together  into  one  large  mass,  but, 
when  so,  the  latter  retains  the  characters  of 
indolence,  etc. 

4.  Date  of  Appearance.  —  It  develops 
during  the  first  or  second  week  of  syphilitic 
chancre. 

5.  Size. — The  glands  are  usually  only 
slightly  enlarged. 

6.  Induration. — The  glands  are  specifi- 
cally indurated,  feeling  like  cartilage  or 
wood. 

7.  Evidence  of  Inflammation.  —  None; 
the  glands  are  freely  movable  among  the 

34 


13.  Not  transmis-         13.  Not  transmis- 
sible, sible. 

14.  Very   rare,  if        14.  Same, 
at  all  possible. 

15.  Glands     are        15.  Same, 
very  rarely  involved. 
Inflammatory     bubo 

may   occur,  virulent 
bubo  is  impossible. 

16.  Inflammatory         16.  Same, 
lymphangitis      alone 

possible. 

17.  Good  in  all  re-        17.  Same. 

spects. 


18.  Same. 


18.  Same. 


Bubo  of  Chancroid, 

1.  It  may  be  simple  (inflammatory),  such 
as  might  attend  any  inflammatory  lesion,  or 
virulent. 

2.  It  is  a  complication  occurring  about 
once  in  three  cases. 

3.  Usually  consists  of  a  single  gland  in 
any  region  of  the  body.  In  the  groin  it 
may  be  bilateral.  It  is  never  a  group  of 
small,  movable  glands. 


4.  There  is  no  fixed  period  of  appear- 
ance. 

5.  The  gland  is  greatly  enlarged. 

6.  No  hardness  except  inflammatory. 


*!.  Every   appearance   of  inflammation. 
The  gland  becomes  fixed  (peri-adenitis),  the 


530 


SYPHILIS. 


Swphiliiic  Bubo. 

tissue.  The  skin  is  neither  adherent  nor 
rcJ,  nor  is  there  any  pain.  The  most 
prominent  feature  of  the  swelling  is  its  in- 
dolence, 

8.  Termination  always  in  resolution,  ex- 
cept in  occasional  cases,  where,  from  sim- 
ple inflammation  or  strumous  degeneration, 
suppuration  ensues. 

9.  Auto-Inoculahiliti/. — In  cases  of  sup- 
puration the  pus  is  not  auto-inoculable.  The 
abscess  docs  not  become  a  chancre,  or  a 
chancroid  ulcer.  It  docs  not  extend,  and 
never  becomes  phagedenic. 

10.  Kahiral  duration  is  a  few  weeks  or 
months. 

11.  Proffnos^is  good  as  far  as  local  re- 
sults are  concerned,  but  the  patient  invari- 
ably has  syphilis. 

12.  Locaf  treatment  inefPective,  except  for 
complications  ;  general  treatment  of  doubt- 
ful efficacy,  but  sometimes  serviceable. 


Syphilitic  Lymphangitis. 
1.  Occurs  only  in  case  of  syphilis,  and 
has  peculiar  characters. 


2.  Feels  hard,  like  the  vas  deferens,  of 
the  size  of  a  knitting-needle,  or  of  a  goose- 
quill  ;  no  pain  on  erection  or  on  handling. 

3.  Skin  uncolored. 

4.  Termination  by  gradual  resolution. 
Very  rarely  there  is  suppuration ;  but,  in 
such  cases,  the  pus  discharged  is  not  auto- 
inoculable. 

6.  Treatment  unnecessary,  and  of  little 
effect,  except  in  case  of  inflammatory  com- 
plication. 


Bubo  of  Chancroid, 

skin  adherent,  the  part  feels  hot,  there  is 
pain,  the  skin  reddens,  the  prominent  feat- 
ures are  those  of  inflannnation. 

8.  Teriiiinatiou  occasionally  by  resolu- 
tion, usually  by  su]ipunition.  Viiulent  bubo 
invariably  suppurates,  and  becomes  an  open 
chancroid  ulcer. 

9.  When  the  bubo  is  inflammatory,  the 
pus  is  not  auto-inoculable ;  where  it  is  viru- 
lent, the  pus  is  invariably  readily  auto-in- 
oculable. Such  an  abscess  becomes  a  true 
chancroid,  and  may  extend  or  become  pha- 
gedenic. 

10.  Natural  duration  is  a  few  weeks, 
or  many  months,  as  a  chancroid ;  possibly 
years,  if  it  becomes  phagedenic. 

11.  Prognosis  good  for  Inflammatory, 
less  so  for  virulent  bubo,  esi)ecia]ly  if  it 
becomes  phagedenic,  in  neither  case  docs 
syphilis  follow. 

12.  Local  treatment  useful  and  necessary 
to  avert  suppuration,  cure  chancroid  left 
by  virulent  bubo,  and  lessen  complications. 
Mercury  harmful.  Antisyphilitic  treatment 
absolutely  useless. 

Lymphangitis  of  Chanci-oid. 

1.  Exists  as  simple  inflammatory  lym- 
phangitis, or  in  virulent  form ;  the  former 
liable  to  complicate  any  inflammatory  affec- 
tion, the  latter  found  only  with  chancroid. 

2.  Some  inflammatory  hardness.  Pain 
on  erection  and  on  handling. 

3.  Skin  red  over  inflamed  vessel. 

4.  Termination  by  resolution  or  suppu- 
ration. Virulent  lymphangitis  invariably 
suppurates,  in  which  case  the  pus  discharged 
is  auto-inoculable,  and  the  openings  become 
chancroids. 

5.  Local  treatment  advisable  to  quiet 
pain,  avert  suppuration,  or  limit  extent  and 
severity  of  chancroids  left  behind  by  the 
suppuration  of  virulent  lymphangitis. 


GENERAL   SYPHILIS. 


Usage  has  adopted  the  name  "primary  syphilis"  for  the  syphilitic 
chancre  and  its  accompanying  adenitis  and  lymphangitis.  These 
manifestations,  although  the  expression  of  constitutional  poisoning, 


GENERAL   SYPUILIS.  531 

are  never  themselves  general,  but  always  strictly  local.  A  chancre 
never  does  nor  can  appear  elsewhere  than  at  that  point  through  which 
the  poison  first  entered  the  body,  llcncc  inherited  syphilis  has  no 
primary  stage,  but  is  general  from  the  start.  The  adenitis  constituting 
syphilitic  bubo  invariably  affects  the  gland  or  glands  in  direct  com- 
munication with  the  lymphatic  trunks  coming  from  the  chancre  ;  the 
other  lymphatic  glands  of  the  body,  which  may  become  indolently  en- 
larged, do  so  only  after  the  second  period  of  incubation.  The  latter 
do  not  belong  to  the  primary  period,  but  form  a  part  of  general  syphi- 
lis. And  so  of  the  lymphangitis  of  primary  syphilis,  it  affects  only 
those  vessels  passing  between  the  chancre  and  the  syphilitic  bubo. 

Hence  primary  syphilis,  so  far  as  its  manifestations  go,  is  purely 
local.  Not  so  with  general  syphilis.  There  is  no  organ  or  tissue  of 
the  body  through  which  it  may  not  manifest  its  presence  by  symptoms, 
or  uj)on  which  it  may  not  exercise  its  power.  The  lymphatic  glands 
all  over  the  body  may  suffer,  some  habitually  more  than  others.  The 
skin  from  crown  to  sole,  the  nails,  the  hair  (the  teeth  in  inherited  dis- 
ease), and  the  mucous  membranes,  especially  around  the  natural  ori- 
fices, have  their  peculiar  affections,  due  to  syphilis.  The  eye  and  the 
testicle  do  not  escape,  and  each  and  every  viscus  is  liable  to  be  invaded, 
as  are  all  the  tissues,  connective,  fibrous,  muscular,  cartilage,  bone, 
brain,  nerve,  and  vessel.  Not  only  this,  but  the  all-embracing  arms 
of  general  syphilis  include  the  functions  as  well,  any  of  which  may  be 
disordered  by  it,  and  each  and  all  of  the  special  senses  may  be  perverted 
or  destroyed — including  the  sexual  appetite.  The  symptoms  of  all 
the  forms  of  local,  special,  or  general  paralysis  of  motion  or  sensation 
may  be  occasioned  by  syphilis.  Finally,  the  intellect  may  succumb. 
Acute  and  chronic  mania,  dementia,  lunacy,  idiocy,  all  the  above  and 
many  more,  form  a  category  of  symptoms  comprehended  under  the 
one  term  general  syphilis. 

General  syphilis  has  been  arbitrarily  divided  into  a  secondary  and 
tertiary  stage.  For  convenience  of  descrijotion  and  treatment,  such  a 
division  is  a  good  one,  and  will  be  retained  in  this  treatise. 

Secondary  sypliilis  includes  all  the  earlier  affections  of  the  tegu- 
mentary  expansions,  cutaneous  and  mucous,  and  many  of  the  lighter 
affections  of  the  eye,  testicle,  and  other  glands,  with  some  of  the  vari- 
eties of  nervous  syphilis. 

Tertiary  sypliilis  follows  secondary,  and  consists  of  the  later  and 
the  ulcerative  skin-affections,  the  deeper  lesions  of  connective  tissue, 
muscle,  bone,  cartilage,  and  of  the  internal  organs  (visceral  syphilis), 
with  the  deeper  and  more  serious  lesions  of  the  eye,  testicle,  brain, 
and  all  morbid  conditions  occasioned  by  what  is  known  as  gummy 
deposit. 

The  line  between  secondary  and  tertiary  syphilis  is  not  always  well 
marked,  and,  although  in  typical  cases  the  lesions  become  progressively 


532  SYPHILIS. 

deeper,  commencing  as  mere  efflorescences  in  the  secondary  stage,  and 
gradually  increasing  in  severity  to  the  most  extensive  ulcerations  and 
destructions  of  bono  and  cartilage  in  the  tertiary,  yet  some  of  the 
symptoms  naturally  belonging  to  the  secondary  group,  as  the  mucous 
patch  and  scaly  eruptions,  frequently  crop  out  in  the  tertiary  stage, 
while  more  rarely  nodes  come  on  with  early  syphilis,  and  occasionally 
most  extensive  ulcerative  or  other  tertiary  (gummy)  lesions  a])j»car 
within  the  first  few  months  after  chancre,  perhaps  all  the  lighter  sec- 
ondary eruptions  liaving  been  omitted. 

Til  is  latter  form,  where  tertiary  symptoms  come  on  in  place  of  the 
secondary,  is  called  '' malignant  syphilis."  The  former  variety  is 
known  as  "irregular  syphilis." 

Inherited  and  nervous  syphilis  will  be  described  separately. 

Certain  of  the  eruptions  which  occur  late  in  the  secondary  stage 
and  early  in  the  tertiary  have  been  grouped  by  Ilardy  under  the  title 
of  "intermediary  syphilides."  The  distinction  drawn  between  sec- 
ondary, intermediary,  and  tertiary  syphilitic  symptoms  is  nsefiil  as  a 
guide  to  treatment.  Mercury,  as  a  rule,  is  advantageous  in  propor- 
tion to  the  nearness  of  the  symptoms  for  which  it  is  given  to  the  pri- 
mary lesion  (chancre),  while  iodine  is  nearly  a  specific  for  the  later 
manifestations.  The  intermediary  symptoms  require  both  medicines 
combined. 

Secondary  syphilis  lasts  often  a  year,  sometimes  two  or  more. 

Tertiary  syphilis  (except  as  malignant)  does  not  commence  till 
after  the  expiration  of  at  least  one  year  from  the  appearance  of  chancre. 
It  may  never  show  itself,  or  may  appear  after  a  period  of  health  of 
many  years,  often  five  or  ten,  sometimes  as  late  as  fifty-two  (Fournier). 
There  can  be  no  absolute  certainty  about  the  dates  of  syphilis,  or 
about  what  symptoms  will  appear.  The  whole  secondary  stage  may 
be  skipped  under  treatment,  or  even  without  treatment,  some  late  ter- 
tiary ulceration  alone  evidencing  the  fact  that  the  patient  had  gcncj-al 
poisoning  at  all. 

Syphilides. — The  most  conspicuous  symptoms  of  general  syphilis 
affect  the  skin,  and  are  known  as  syphilides  or  syphilodermata.  The 
prominent  primary  lesion  characterizing  the  cutaneous  affection  gives 
it  its  name,  and  in  syphilis  most  of  the  confusing  epithets  of  derma- 
tology may  be  dispensed  with.  Thus,  if  a  papule  be  the  prominent 
lesion,  or  a  vesicle,  or  a  pustule,  the  affection  is  not  necessarily  called 
a  lichen,  or  eczema,  or  impetigo,  but  a  "papular,"  "vesicular,"  or 
"pustular  syphilide,"  as  the  case  may  be  ;  adding  "general,"  or  "in 
groups,"  according  to  the  physical  distribution  of  the  lesion.  Ulcer- 
ated syphilides,  again,  are  spoken  of  as  superficial  or  deep,  serpiginous 
or  perforating,  making  the  nomenclature  of  syphilis  exceedingly  sim- 
ple, since  the  words  themselves  describe  the  affection. 

Prognosis. — As  to  the  character  of  the  general  syphilis  which  is 


PROGNOSIS.  533 

to  follow  upon  a  given  chancre,  the  peculiarities  of  the  indiviflual  have 
more  to  do  with  it  than  anything  else,  excepting,  of  counse,  judicious 
treatment.  Certain  authors  have  advanced  that  phagedenic  syphilitic 
chancre  is  followed  by  severcv  syphilis.  The  condition  of  the  patient 
allowing  him  to  have  phagedena,  it  is  fair  to  presume,  is  also  such  as 
will  cause  him  to  suffer  severely  from  his  syphilis;  but  it  docs  not 
necessarily  follow,  for  the  cause  of  the  phagedena  might  have  been  a 
local  one  or  one  only  acting  temporarily,  and  then  the  succeeding  gen- 
eral syphilis  might  be  mild.  Nor  indeed  does  Diday's  idea  prove  trust- 
worthy, that  the  length  of  incubation  of  the  chancre,  or  the  length  of 
secondary  incubation,  portends  the  character  of  the  general  syphilis 
which  is  to  follow.  There  is  undoubtedly  a  measure  of  truth  in  this, 
for,  if  the  quantity  or  quality  of  the  poison  absorbed,  or  the  state  of 
the  individual,  be  such  as  to  allow  the  first  local  and  general  mani- 
festations of  the  disease  to  be  long  delayed,  it  is  reasonable  to  suppose 
that  the  whole  course  of  the  malady  will  be  mild.  The  same  natural 
inference  may  be  made  with  some  reason  in  connection  with  the  mild- 
ness or  severity  of  the  chancre.  But  neither  of  these  rules  is  reliable. 
Not  infrequently  we  see  cases  of  protracted,  severe,  obstinate  disease 
attending  a  chancre  of  very  long  incubation.  And  the  syphilide  fol- 
lowing the  chancre  which  never  ulcerates  is  sometimes  more  intracta- 
ble than  the  same  eruption  following  a  large,  excavated,  ulcerated, 
primary  lesion.  Syphilis  acquired  from  a  mild  case  may  be  severe  or 
mild.  The  following  three  cases  will  tend  to  demonstrate  the  fact 
that  individual  peculiarity  has  more  to  do  with  the  form  of  syphilis 
than  anything  else  : 

In  1865,  in  the  cutaneous  wards  of  St.  Louis  Hospital,  under  Prof. 
Hardy's  care,  were  two  cases,  man  and  wife.  The  man  had  severe 
malignant  syphilis,  with  large  gummy  deposits  in  his  skin  ;  some  of 
them  ulcerating  ;  all  occurring  within  a  few  months  after  chancre. 
This  man  had  poisoned  his  wife  while  he  yet  carried  his  chancre.  She 
had  a  very  mild  papulo-erythematous  syphilide,  bearing  none  of  the 
characters  of  malignancy.  The  woman  from  whom  the  man  acquired 
his  disease  was  sought  out  and  found.  She  also  was  a  simple  case  of 
ordinary  mild  syphilis.  The  ]3oison  in  these  three  cases  was  identical, 
handed  directly  from  one  to  the  other,  but  the  results  were  so  widely 
different  that  it  would  have  been  hard  to  convince  a  layman  of  their 
identity  of  origin.  What  the  idiosyncrasy  is  which  makes  syphilis  bad 
in  one  case  and  light  in  another  can  not  be  affirmed.  Scrofulous  and 
strongly  lymphatic  individuals,  although  a  little  more  prone  to  suffer 
from  severe  suppurative  and  ulcerative  lesions  than  others,  are  by  no 
means  the  only  ones  who  have  severe  attacks.  The  most  obstinate  and 
long-enduring  cases  are  frequently  found  in  connection  with  the  gouty 
diathesis,  the  predominant  eruptions  in  such  cases  being  scaly  and  tu- 
bercular, and  nervous  syphilis  being  not  uncommon. 


534  SYPUILIS. 

Perhaps  the  best  light  that  can  be  thrown  upon  the  question  of 
prognosis  may  be  derived,  not  from  the  time  of  ajiitearance,  but  from 
the  character  of  the  first  eruption  of  the  secondary  period.  If  this 
eruption  be  scanty  and  i)urely  erytiiematous  (roscoUi),  or  even  papular, 
the  case  will  probably  be  much  more  mild  than  if  the  earliest  eruption 
were  vesicular,  or,  still  worse,  })ustular,  especially  if  comi)licated  early 
by  iritis.  Finally,  if  extensive  tubercular  eruptions  and  ulcerations 
appear  in  place  of  the  usual  secondary  symptoms,  the  case  is  one  of 
malignant  syphilis,  and  the  j)rognosis  becomes  grave.  There  is  no 
just  foundation  for  the  opinion  which  has  been  advanced,  that  syphilis 
acquired  from  a  secondary  lesion  runs  a  more  severe  course  than  if  it 
were  acquired  from  contact  with  a  chancre.  As  far  as  the  virulence 
of  the  poison  is  concerned,  the  converse  of  the  above  proposition  would 
theoretically  appear  more  probable,  for  the  secretion  of  a  syphilitic 
chancre  seems  more  readily  inoculablc  than  that  of  secondary  lesions. 
Further,  it  is  certain  that  as  the  disease  advances  its  transmissibility  by 
inheritance  declines.  A  syphilitic  mother  will  abort  in  her  early  preg- 
nancies, then  produce  a  dead  child  at  or  before  term  ;  next  a  child 
who  may  die  in  a  few  weeks,  with  specific  eruptions  ;  then  another 
who  may  have  only  mild  symptoms  of  inherited  syphilis  ;  and,  finally, 
in  the  tertiary  stage  of  the  mother,  her  children  may  be  born  healthy, 
and  continue  so  indefinitely.  Youth  and  strength  do  not  insure  a 
mild  attack  to  a  patient  with  syphilis,  nor  does  age  or  debility  neces- 
sarily imply  a  severe  one  ;  on  the  contrary,  old  age  generally  is  that 
period  of  life  most  kindly  treated  by  syphilis.  Babies  with  inherited 
syphilis  suffer  more  than  any  other  class.  The  malady  is  often  fatal 
with  infants.  Next  in  severity  come  the  cases  acquired  in  early  man- 
hood— from  eighteen  to  twenty-eight.  Malignant  syphilis  has  this  to 
be  said  in  its  favor,  that,  although  exceptionally  severe,  when  the  out- 
burst is  well  over  the  malady  often  ajipears  to  have  exhausted  itself ; 
and  such  patients,  in  my  opinion,  are  less  apt  to  suffer  seriously  in 
later  life  than  some  of  those  who  have  very  simple  lesions  in  the  earlier 
part  of  their  malady. 

Excesses  of  every  sort,  of  wine,  of  women,  of  work,  are  liable  to 
intensify  the  type  and  duration  of  existing  syphilis.  Climate  also  seems 
to  have  some  influence.  Treatment  throws  confusion  into  the  natural 
order  of  appearance  of  the  eruptions,  postpones  their  outbreak,  light- 
ens their  character,  shortens  their  duration,  and,  in  the  most  favorable 
cases,  almost  prevents  them  entirely. 

All  local  irritations  tend  to  call  out  eruptions  at  the  points  irri- 
tated, and  to  maintain  them  there.  A  child  born  with  inherited 
syphilis  may  give  no  evidence  of  his  malady  until  he  is  vaccinated, 
whereupon  an  eruption  may  speedily  appear,  become  general,  and  be 
attributed  to  the  innocent  vaccination.  A  blister  in  the  same  way, 
even  upon  an  adult,  may  call  out  dormant  syjihilis.    Not  infrequently 


DURATION.  535 

a  cold,  great  heat,  any  excess,  a  fatigue,  an  irritating  or  sulphur  bath, 
friction,  electrization,  maybe  the  exciting  cause  calling  dormant  syph- 
ilis into  action  and  occasioning  an  eruption.  Patients  who  work  much 
with  the  hands  are  more  liable  than  others  to  eruptions  of  the  palms. 
Perspiration  upon  overlying  portions  of  skin  often  intensifies  a  given 
eruption  at  such  points,  as  under  the  female  breast,  around  the  um- 
bilicus, between  the  scrotum  and  the  thigh.  Lack  of  cleanliness  around 
the  anus  and  under  the  prepuce  is  a  powerful  predisposing  cause  to 
mucous  patches,  while  the  use  of  tobacco  chewed  or  smoked  is  pro- 
verbial for  its  power  of  originating  and  maintaining  the  same  lesions 
in  the  mouth.  A  mucous  patch  of  the  tongue  is  often  occasioned  and 
indefinitely  prolonged  in  a  syphilitic  subject  by  friction  of  that  mem- 
ber against  the  rough  edge  of  a  tooth,  and  the  suction  of  a  baby  on  the 
nipple  calls  out  mucous  patches  there.  Wounds  upon  a  syphilitic  sub- 
ject sometimes  provoke  the  development  of  a  sy]3hilitic  outbreak  around 
them  ;  sometimes  they  heal  kindly  as  upon  a  healthy  person,  some- 
times they  fail  to  heal,  and  gradually  put  on  the  characters  of  syphi- 
litic ulcerations.  There  is  considerable  difference  of  opinion  in  the 
profession  upon  this  point.  When  a  bone  breaks  in  a  syphilitic  sub- 
ject, even  in  one  with  latent  syphilis,  who  has  apparently  long  been 
well,  it  may  fail  to  unite  unless  the  patient  is  pretty  thoroughly  dosed 
with  the  iodide  of  potassium.  A  knowledge  of  all  these  facts  is  of 
great  importance  in  making  a  general  prognosis. 

Bad  hygienic  surroundings  materially  aggravate  and  prolong  syphi- 
litic manifestations,  to  such  an  extent,  indeed,  as  often  to  render 
specific  treatment  absolutely  unavailing  or  even  harmful,  until  the 
patient  is  removed  from  such  surroundings. 

DuKATiois'  OF  Gejsteral  Stphilis. — There  is  no  disease  so  protean 
in  its  form  as  syphilis. 

"  Age  can  not  wither  her,  nor  custom  stale  her  infinite  variety." 

Syphilis  finds  expression  through  every  tissue.  Its  symptoms 
simulate  those  of  a  vast  number  of  other  diseases,  and  some  of  its 
forms  may  be  so  obscure  as  to  baffle  accurate  diagnosis  without  the 
assistance  of  the  touchstone  treatment.  So  true  is  this,  that  it  has 
passed  into  a  proverb  among  certain  of  the  less  well  informed  of  the 
profession,  in  face  of  an  obscure  disease,  "  If  you  do  not  know  what 
to  do,  treat  the  patient  for  syphilis. "  The  unscientific  looseness  of 
such  a  course  needs  no  comment ;  but  the  existence  of  the  proverb  is 
the  best  argument  to  substantiate  the  protean  type  of  syphilis.  Only 
minute  and  careful  investigation  into  the  more  obscure  manifestations 
of  the  disease  can  lead  to  accuracy  of  diagnosis,  which  is  of  more  impor- 
tance in  this  than  perhaps  in  any  other  malady.  Hence  the  difficulty 
of  saying  when  syphilis  has  ended,  or  indeed  of  deciding  that  it  ever 
does  end,  since  it  so  often  permanently  modifies  the  diathesis  of  the 


536  SYPHILIS. 

individual  who  has  suffered  from  it.  Syphilis  may  occur  in  so  mild 
a  form  that  the  patient  may  never  know  he  has  it ;  or,  again,  with 
such  intensity  that  extensive  lesions  of  the  skin,  bone,  and  other  tis- 
sues, may  come  on  within  the  lirst  year,  with  i)aralytic  symptoms  of 
great  extent  and  severity.  Syphilis  may  manifest  itself  as  a  mild 
eruption  after  chancre,  disappearing  possibly  without  treatment,  and 
then  (exceptionally,  it  is  true)  lie  latent  for  many  years,  as  long  as 
fifty-two  years,  to  reappear  with  characters  due  only  to  syphilitic  dis- 
ease. In  Fournier's  case,  a  gentleman  of  seventeen  had  acquired 
chancre,  followed  by  some  secondary  eruptions,  which  were  pronounced 
syphilitic.  No  further  symptoms  had  appeared  until  the  age  of  sixty- 
nine — fifty-two  years  after  the  chancre — when  he  had  suffered  from 
syphilitic  caries  of  the  upper  jaw.  At  seventy-two  he  applied  to 
Fournier  for  a  gummy  tumor  of  the  thigh,  which  got  rapidly  well 
under  the  iodide  of  potassium.  Now,  in  this  case,  had  the  patient 
died  at  the  age  of  sixty-eight,  he  might,  with  seeming  justice,  have 
been  reported  as  an  instance  of  cure,  for  over  half  a  century  would 
have  intervened  since  his  last  syphilitic  symptom.  I  have  a  personal 
case  where  syphilis  was  latent  for  about  forty  years. 

This  one  case  gives  at  a  glance  the  practical  answer  to  the  whole 
question  of  the  duration  of  syphilis.  Every  physician  of  any  consider- 
able experience  with  syphilis  can  recall  analogous  cases,  though,  per- 
haps, less  striking.  Syphilis,  once  acquired,  stamps  its  impress  upon 
the  individuality  of  the  patient,  and  becomes  a  part  of  him,  and  no 
power  on  earth  in  a  given  case  can  say  when  that  impress  disappears. 
A  half  century  may  pass  away  and  the  trail  of  the  serpent  be  still  visi- 
ble. This  is  a  fact,  and  as  such  must  be  recognized.  It  is  of  vast 
practical  importance,  and  to  shut  our  eyes  to  it  would  be  folly.  That 
we  do  not  so  shut  our  eyes,  even  those  of  us  who  believe  in  an  early  and 
radical  cure  of  syphilis,  is  sufficiently  shown  by  the  avidity  with  which, 
in  doubtful  cases  of  skin  or  bone  disease,  the  history  of  the  patient  is 
carefully  inquired  into  for  a  record  of  pre-existing  syi)hilis,  which,  if 
found,  no  matter  how  distant,  makes  the  diagnosis,  establishes  the 
treatment,  and  often  leads  to  a  cure. 

Yet,  in  spite  of  this  assertion,  who  shall  say  that  syphilis  may  not 
be  cured  ?  Occasionally  cases  are  seen  where  syphilitic  chancre  is 
acquired  a  second  time,  followed  by  crops  of  secondary  eruptions,  and 
surely  in  these  cases  the  old  syphilis  must  have  been  cured,  or  the  new 
one  could  not  have  appeared.  Yet  in  some  of  these  cases  tertiary 
symptoms  have  been  present  when  the  second  chancre  was  acquired, 
but  this  again  only  coincides  with  the  evidence  furnished  by  clinical 
observation  ;  namely,  that  the  virulence  of  syphilis  disappears  in  the 
late  tertiary  period  ;  that  during  this  period  neither  the  blood  nor  the 
pathological  secretions  will  infect  a  healthy  subject  with  the  disease, 
and  that  such  patients  may  be  the  parents  of  perfectly  healthy  chil- 


DURATION.  537 

dren,  who  never  manifest  the  faintest  sign  of  syphilitic  poisoning. 
The  necessary  conclusion,  then,  is  this  :  that  while  symptoms  wiiich 
can  depend  upon  no  other  disease  than  syphilis  may  crop  out  at  any 
period  during  the  life  of  a  patient  who  has  once  had  syphilitic  clian- 
cre,  yet  the  virulence  of  the  disease  and  its  contagious  properties  do 
die  away  in  time,  what  are  left  being  more  properly  sequelae  in  the 
received  acceptation  of  that  term. 

The  above  is  the  possibility  of  the  duration  of  the  effects  of  syphilis, 
and  must  be  recognized  by  every  intelligent  physician  who  wishes  to 
accept  facts  and  desires  to  view  syphilis  in  a  practical  light.  The 
probability  of  the  disease  in  most  cases,  however,  is  that  its  manifesta- 
tions will  disappear  finally  after  a  few  years,  and  this  under  intelligent 
management  becomes  almost  a  certainty. 

Syphilis  is  no  longer  the  terrible  scourge  it  proved  itself  in  the 
fifteenth  century.  It  is  rarely  fatal  except  in  the  visceral  form,  and 
the  majority  of  patients  escape  this  stage  entirely.  It  is  hardly  too 
much  to  state  that,  of  the  two  diseases,  gonorrhoea  and  syphilis,  the 
former  sends  more  patients  to  the  tomb  than  the  latter.  ISIeither  kills 
directly ;  both  do  so  by  their  sequelae.  The  classical  mode  of  death 
as  resulting  from  gonorrhoea  is  through  stricture,  to  fatal  bladder  and 
kidney  disease  ;  'and  whatever  the  ratio  of  deaths  to  attacks  may  be  in 
the  two  diseases,  it  is  highly  probable  that  more  deaths  actually  occur 
from  gonorrhcBa  as  their  first  cause  than  from  syphilis. 

Syphilis,  again,  has  the  advantage  of  being  a  manageable  disease. 
Its  symptoms  yield  to  treatment  far  more  readily  than  do  those  of  any 
other  chronic  malady,  and  it  is  precisely  in  that  period  where  the  dis- 
ease is  most  destructive  to  tissue  and  to  life,  the  tertiary  stage,  that 
remedies  are  the  most  brilliantly  effective.  Syphilis,  as  encountered 
in  the  higher  walks  of  life,  is  a  mild  but  terribly  lurking  and  insidious 
disease.  It  may  escape  attention  altogether.  Many  ladies  come  by  it 
honestly,  but  never  know  they  have  it.  Children  develop  some 
obscure  symptoms,  the  significance  of  which  escapes  not  only  the 
parents  but  also  the  family  physician  ;  and  even  a  man  may  get  chan- 
cre, followed  by  some  light  eruption,  consider  it  of  no  importance, 
and  get, well  spontaneously,  marry  and  have  healthy  children,  himself 
remaining  entirely  free  from  any  evidence  of  the  disease,  and  dying  in 
a  green  old  age. 

SypJiilis  and  Marriage. — The  practical  question  in  this  context  is  : 
During  what  time  are  symptoms  liable  to  recur  before  that  long  latent 
period  may  be  expected,  which  is  to  terminate  all  manifestations  of 
disease,  and  in  which  the  patient  is  certainly  well,  probably  cured  ? 
Or,  still  more  practically,  the  question  may  be  put :  If  a  patient  pre- 
sents himself  with  syphilitic  chancre,  at  what  period  may  he  safely 
marry  ? 

Roughly,  and  on  the  average,  this  last  question  may  be  answered 


538  SYPHILIS. 

by  saying,  after  about  four  years  ;  or,  to  be  safer,  at  a  period  not 
earlier  than  four  years  after  chancre,  when  it  can  be  proved  that  no 
svnii)tom  of  syphilis  has  shown  upon  the  ])atient  for  a  year,  during 
which  year  he  has  been  at  least  six  months  without  treatment.  And, 
indeed,  it  is  wiser  to  say  to  any  one  asking  the  question  that  it  is  bet- 
ter not  to  marry  until  five  years  after  chancre,  although  such  applicant 
must  be  informed  that  many  patients  marry  with  im])unity  at  a  much 
shorter  period.  For  the  female  I  think  live  years  is  little  enough,  and 
more  would  be  better.  Patients  do  marry  in  all  stages  of  the  malady. 
Fournier*  says  that  out  of  572  private  female  patients  with  syphilis 
81  were  young  women  who  had  contracted  the  disease  from  their  hus- 
bands during  the  first  few  months  after  marriage. 

Patients  Avill  marry  before  they  are  well  in  spite  of  every  caution 
thev  may  be  given,  but  in  such  case  they  should  be  made  to  bear  the 
responsibility  themselves.  A  gentleman  came  to  me  once  with  a 
chancre,  stating  that  the  cards  were  out,  and  that  he  must  and  would 
marry  in  a  few  days.  I  could  not  dissuade  him.  He  married.  On 
the  ground  of  preventing  conception,  in  which  his  wife's  wishes  coin- 
cided with  his  own,  he  wore  a  protecting  cover  during  intercourse  for 
a  period  of  nearly  three  years — being  constantly  under  treatment,  and 
his  wife  ignorant  that  he  was  sick.  After  three  years  I  allowed  him 
to  have  relations  naturally.  It  is  now  more  than  a  year  since  he  re- 
ceived this  permission.  His  wife  has  not  become  pregnant.  She  is 
well,  and  he  has  remained  so.  In  a  doubtful  case  of  a  man  who  per- 
sists in  marrying  too  soon,  it  is  well  to  insist  that  he  shall  continue 
specific  treatment  until  his  Avife  shall  have  become  pregnant  at  least. 

Yet  it  is  not  safe  to  give  a  positive  guarantee  to  a  patient  even  in 
five  years.  Presumably  he  is  incapable  of  communicating  the  disease, 
but  relapses  of  symptoms  of  a  contagious  character  do  certainly  occur 
in  some  patients  even  after  this  period.  Under  all  circumstances  a 
patient  with  syphilis  who  marries  should  watch  himself  carefully,  and 
not  have  contact  with  his  wife  if  there  is  upon  his  penis  at  the  time 
any  moist  lesion,  excoriation,  or  abrasion,  no  matter  how  innocent 
such  lesion  may  appear,  or  what  may  have  been  its  cause.  The  more 
prolonged  and  consistent  the  first  mercurial  course  has  been,  the  better 
the  guarantee  of  immunity  which  can  be  given  the  patient. 

Causes  of  the  Protracted  Duration  of  Syphilis.— Those  patients 
most  often  do  badly,  other  things  being  equal,  who  follow  irregular 
and  uneven  courses  of  treatment,  now  pushing  medication  to  excess,  in 
the  hope  of  killing  the  disease,  which  is  impossible,  now  giving  up  all 
treatment  in  despair.  It  is  very  rare  for  bad  symptoms  to  appear  upon 
a  patient  who  falls  into  the  hands  of  a  conscientious  physician,  one  who 
recognizes  that  the  disease  can  not  be  jugulated,  that  the  eliminative 
and  not  the  abortive  treatment  must  be  followed,  and  who  quietly  and 
*  "Syphilis  and  Marriage,"  1880. 


INFLUENCE   OF   GOUT   AND   SCROFULA.  539 

steadily  pursues  the  enemy  tlirough  its  periods  of  repose  as  well  as 
during  its  moments  of  eruption,  confident  tliut,  by  mildly  and  persist- 
ently keeping  up  this  treatment  by  extinction,  he  will  triumph  at  last 
over  the  disease.  In  mild  cases  so  treated  there  may  be  but  one  faint 
eruption,  or  perhaps  but  a  few  little  spots,  with  epitrochlear,  glandular 
induration  and  a  few  mucous  patches,  to  mark  the  disease,  the  whole 
of  the  symptoms  only  lasting  a  few  months  after  chancre,  and  the  pa- 
tient's after-life  being  healthful.  This,  however,  is  the  exception. 
Ordinarily  some  mild  symptoms  continue  to  crop  out  from  time  to 
time  for  perhaps  on  an  average  two  to  three  years,  after  which  comes 
the  period,  be  it  cure  or  not,  during  which  the  patient  bears  all  the 
marks  of  health,  is  unable  to  communicate  the  disease,  and  reproduces 
healthy  offspring. 

Finally,  there  are  exceptional  examples  where  late  tertiary  symp- 
toms appear  after  long  years  of  latency,  as  already  observed  ;  of  malig- 
nant syphilis,  which  is  controlled  with  difficulty  by  treatment ;  and  of 
other  inveterate  specimens  of  disease  where  relapse  after  relapse  fol- 
lows through  long  series  of  years,  perhaps  in  spite  of  a  continuous  in- 
telligent treatment. 

These  last  cases  may  be  mostly  ranged  under  three  heads  : 

1.  Those  living  in  bad  hygienic  surroundings,  and  giving  them- 
selves up  to  excesses  of  every  sort. 

2.  Patients  peculiarly  susceptible  to  the  disease.  Thus  I  have  sev- 
eral times  remarked  a  profound  susceptibility  to  syphilis  to  exist  in  a 
given  family  otherwise  healthy.  In  many  instances  I  have  known  two 
brothers  or  a  father  and  son  to  acquire  the  disease,  and  both  to  have 
it  in  about  the  same  general  type.  I  have  now  under  my  charge  two 
brothers  with  syphilis.  They  had  a  third  brother  who  died  of  cerebral 
syphilis  in  early  manhood.  The  present  two  cases  are  inveterately  in- 
tense, chronic,  and  relapsing  in  type,  and  one  of  them  has  had  cerebral 
lesions  of  the  most  serious  character.  All  derived  their  syphilis  at 
different  periods  of  life  from  different  sources,  and  all  possessed  excep- 
tionally good  health  in  other  respects,  and  came  of  a  healthy,  long- 
lived  stock.  One  gave  his  disease  to  his  mistress,  who  had  it  in  an 
exceptionally  mild  form. 

3.  Patients  possessed  of  a  strong  tendency  to  gout,  or  of  decidedly 
scrofulous  diathesis. 

Inflijencb  of  Gout  and  Scrofula  upon  the  Couese  of  Syphi- 
lis.— Both  gout  and  scrofula  may  exercise  a  disturbing  influence  upon 
the  course  and  the  manifestations  of  syphilis.  In  the  rheumatic  or 
gouty  subject  the  cutaneous  symptoms  partake  of  the  gouty  type.  They 
are  apt  to  be  dry,  erythematous,  papular,  tubercular,  scaly,  of  a  par- 
ticularly livid  red,  of  great  chronicity,  leaving  much  pigmentation 
behind.  Certain  purely  gouty  eruptions  are  almost  indistinguishable 
from  similar  ones  produced  by  syphilis,  and  these,  when  occurring 


540  SYPHILIS. 

upon  a  patient  who  lias  had  syphilis,  give  rise  to  great  difficulties  of 
diagnosis,  and  are  most  often  mistaken  for  syphilides  and  treated  as 
such,  either  without  elfect  or  until  they  spontaneously  disa}ipear,  when 
the  specitic  medication  gets  the  credit  of  the  cure.  Such  gouty  erup- 
tions are  the  dry,  papular  patches  or  single  papules  ahout  the  hands, 
on  the  ]ialnis  or  back,  upon  the  feet  or  elsewhere  ;  scaly  patches,  gen- 
eralized papular  and  scaly  livid  eruptions  on  the  extremities  or  back, 
especially  such  as  occur  during  the  spring  or  fall,  and  during  the  heats 
of  summer  (from  the  acridity  of  the  perspiration).  The  different  forms 
of  psoriasis,  as  seen  upon  an  individual  of  the  gouty  habit,  possess 
many  of  the  characteristics  belonging  to  syphilitic  eruptions,  and  often 
lead  to  error.  These  eruptions  which  have  been  just  mentioned  do  not 
itch  (as  a  rule),  and  their  diagnosis  (when  found  upon  a  syphilitic  pa- 
tient), from  inspection  alone,  is  always  difficult,  sometimes  impossible. 
Treatment  may  be  required  to  solve  tlie  problem.  Syphilides  on  a 
gouty  patient  get  well  quite  promptly,  while  other  eruptions  are  not 
sensibly  affected  by  antisyi^hilitic  remedies. 

Besides  this  simulation  of  syphilis  by  certain  gouty  eruptions, 
whether  they  occur  on  a  patient  who  has  had  syphilitic  chancre  or  not, 
the  gouty  diathesis  tends  to  make  the  type  of  syphilis  an  obstinate  one. 
During  the  employment  of  treatment,  and  in  spite  of  it,  in  some  such 
cases,  a  new  eruption  will  crop  out,  while  the  tendency  to  relapse,  and 
to  the  recurrence  of  scaly,  jjapular,  and  tubercular  patches,  is  some- 
times disheartening.  Finally,  the  gouty  diathesis  seems  to  predispose 
to  the  development  of  nervous  symptoms  in  syphilis,  both  of  the  rheu- 
matic order  in  early  disease  (pain),  and  to  lesions  of  bone,  of  fibrous 
tissue,  and,  later  on,  of  nerve-substance,  such  as  furnish  the  different 
forms  of  paralysis. 

Scrofula,  on  the  other  hand,  leads  to  moist  eruptions  in  syphilitic 
poisoning,  the  vesicular,  pustular,  early  and  late  ulcerative.  Most  of 
the  lymphatic  glands  become  involved,  but  they  are  usually  not  so 
markedly  indurated.  The  eruptions  are  often  slow  in  coming  out,  and 
slow  in  getting  well.  The  cicatrices  of  ulcers  are  not  so  liable  to  be 
deeply  pigmented  ;  they  are  often  somewhat  irregular,  puckered, 
ridged,  and  drawn  like  the  scrofulous  cicatrix,  unlike  the  round,  de- 
pressed, smooth,  thin,  glistening,  non-adherent,  characteristic  cicatrix 
of  syphilis.  The  type  of  the  whole  disease  is  apt  to  be  slow,  chronic, 
pustular,  ulcerative,  inveterate,  often  attended  by  destructive  bony 
lesions.  Again,  in  a  syphilitic  patient,  a  gland  may  suppurate,  and 
then  ulcerate  with  all  the  appearances  of  struma  about  it,  and  yet 
yield  only  to  antisyphilitic  treatment. 

General  Characteristics  of  Sypuilides. — All  the  syphilitic 
affections  of  the  skin  have  certain  general  characteristics  which  stamp 
them  as  a  class.  Every  mark  is  not  possessed  by  each  eruption,  yet 
the  majority  belong  to  each  and  every  syphilitic  lesion  of  the  skin. 


GENERAL   CHARACTERISTICS   OF  SYPIIILIDES.  541 

They  arc   usually   well    marked,    and   may  be  grouped    under  ten 
beads  : 

1.  Polymorphism  of  the  initial  lesion. 

2.  Rounded  form  of  the  patches  of  eruption,  and  of  the  ulcers. 

3.  Livid  color,  like  the  meat  of  raw  ham,  then  coppery  (pig- 
mented), then  gray,  then  white. 

4.  Absence  of  pain  and  itching. 

5.  Earlier  eruptions  superficial  and  generalized,  usually  symmet- 
rical. 

6.  Later  eruptions  in  groups,  involving  the  cutis  vera. 

7.  Scales  white,  usually  not  adherent,  superficial. 

8.  Crusts  greenish,  black,  irregular,  thick,  adherent. 

9.  Ulceration  with  abrupt  edges,  adherent,  not  undermined,  slug- 
gish, and  bleeding  easily. 

10.  Cicatrix  rounded,  depressed,  thin,  non-adherent,  white,  smooth 
at  first,  often  pigmented,  then  clearing  off  from  the  center  toward  the 
circumference. 

To  these  special  characteristics  may  be  added  for  the  earlier  out- 
breaks, the  general  accompanying  phenomena  of  syphilitic  fever,  alo- 
pecia, headache,  osteocopic  pains  (worse  at  night),  analgesia,  anaesthe- 
sia, indolent  lymphatic  ganglia,  iritis,  sore-throat,  and  mucous  patches 
in,  upon,  or  around  the  natural  orifices. 

1.  Polymorphism. — This  applies  to  the  earlier  and  generalized 
eruptions.  With  other  cutaneous  diseases,  it  is  the  exception  to  have 
an  eruption  composed  of  many  elementary  lesions  ;  with  syi^hilis  it  is 
rather  the  rule.  An  erythematous  syphilide  is  usually  also  at  the 
same  time  partly  papular.  The  papular  furnishes  examples  of  ery- 
thematous spots,  and  very  often  some  vesicles,  some  pustules,  and  some 
scales,  and  so  of  the  other  generalized  eruptions.  This  is  partly  ac- 
counted for  by  the  fact  that  the  elementary  lesion  often  develops  in 
successive  crops,  and  therefore  shows  during  its  different  stages  as  an 
erythema,  a  papule,  a  vesicle,  a  pustule,  a  tubercle,  or  a  scaly  spot. 
One  lesion,  however,  always  exists  in  excess,  and  from  this  lesion  is 
the  eruption  named — as,  papular  syphilide. 

2.  Rounded  Form. — In  a  generalized  eruption  the  groups  of  ele- 
mentary lesions  are  gathered  into  rounded  clusters,  but  this  is  more 
specially  shown  in  the  later  circumscribed  syphilides,  be  they  groups 
of  pajmles,  vesicles,  pustules,  tubercles,  or  indeed  ulcerations.  The 
tendency  to  a  rounded  form  of  the  group  is  marked. 

3.  Color. — The  color  of  the  syphilides  is  not  a  frank,  inflammatory 
red,  but  a  vinous,  empurpled  redness,  resembling,  when  well  marked, 
the  raw  meat  of  ham.  This  color  is  found  also  in  many  of  the  gouty, 
papular  eruptions,  and  in  psoriasis,  rarely  with  other  eruptions.  The 
color  of  the  syphilides  passes  by  pigmentation  from  the  dusky,  violet- 
red,  into  what  is  known  as  copper-color,  and  from  there  on  sometimes. 


542  SYPHILIS. 

by  a  deep  pigmcntatiou,  to  brown  or  black,  the  skin  around  the  lesion 
being  usually  also  pigmented  to  a  certain  extent.  This  pigmentary 
coloration  sometimes  lingers  for  years,  but  usually  clears  oiT  after  a 
few  months,  disai)ponring  first  centrally,  the  clearing  oil'  extending 
peripherally  in  all  directions.  Finally,  the  spot  becomes  brilliantly 
white, 

4.  Pain  and  Itching. — The  syphilides  are  not  accompanied  by  any 
itching  or  pain  ;  neither  the  eruptions  nor  the  ulcers  ordinarily  fur- 
nish any  disagreeable  subjective  sensations.  Occasionally  there  are 
some  heat  and  prickling  with  an  eruption  as  it  is  coming  out,  but  it 
uever  amounts  to  actual  itching.  Syidiilitic  ulcerations  are  also  free 
from  pain,  except  as  occurring  upon  dejiendent  portions  of  the  body, 
where  the  imperfect  circulation  tends  to  set  up  some  inflammation 
around  or  in  the  throat,  where  the  constant  motion  seems  often  to 
lead  to  the  same  result.  This  absence  of  subjective  phenomena  is  of 
great  importance  in  diagnosticating  syphilitic  eruptions.  Errors, 
however,  are  liable  to  occur  with  gouty  and  scrofulous  eruptions,  most 
of  which  are  also  entirely  devoid  of  pain  or  itching.  Other  features, 
however,  distinguish  the  latter.  Sometimes  eruptions  are  seen  which, 
although  evidently  syphilitic,  are  yet  attended  by  itching.  In  such 
cases  an  attentive  inquiry  will  usually  disclose  the  cause  of  the  excep- 
tional peculiarity.  The  patient  may  be  found  to  have  a  naturally 
irritable,  itchy  skin,  a  pruritus  which  always  troubles  him,  and  which 
the  syphilitic  eruption  by  no  means  relieves.  He  may  be  afflicted  with 
urticaria  along  with  his  specific  eruption.  Not  uncommonly,  in  hos- 
pital patients,  prurigo  from  pediculi  coexists  with  some  syphilitic- 
exanthem.  I  have  seen  an  eruption  produced  upon  a  patient  with 
chancre  and  gonorrhoea  by  an  overdose  of  copaiba  which  might  have 
given  rise  to  confusion  of  diagnosis. 

Contrary  to  the  rule,  the  earlier  syphilitic  eruptions  of  the  scalp 
are  usually  attended  by  itching. 

5.  The  earlier  eruptions  are  distributed  habitually  all  over  the 
body,  and  are  superficial,  mainly  congestive  in  character.  There  is  no 
deep  alteration,  nor  any  destruction  of  tissue,  as  proved  by  the  fact 
that  the  earliest  eruptions  (erythematous  and  papular)  leave  no  scars. 
Those  coming  a  little  later  leave  faint  scars  (pustular  and  vesicular). 
The  development  tends  to  be  symmetrical,  the  eruption  coming  out 
on  the  flanks  and  sides  of  the  thorax,  the  forehead,  along  the  edge  of 
the  hair,  on  the  sides  of  the  nape  and  the  margins  of  the  nostrils,  on 
the  palms  and  soles,  etc. 

6.  The  later  eruptions  are  grouped  ;  tubercle,  pustule,  or  ulcera- 
tion, whatever  be  the  lesion,  it  is  now  no  longer  generalized,  but 
gathered  into  groups  ;  and  that  the  lesion  is  deep  and  there  is  destruc- 
tion of  tissue,  are  shown  by  the  depression  of  the  cicatrix.  These 
lesions  usually  leave  a  scar  whether  they  ulcerate  or  not,  and  this  dis- 


GENERAL   CnARACTERISTICS   OF   SYPIIILIDES.  543 

tinction  of  leaving  cicatrices  without  previous  ulceration  is  enjoyed  by 
no  other  class  of  eruptions  save  one,  the  scrofulous.  A  tubercular 
non-ulcerated  lupus  will  also  leave  scars,  but  such  scars  are  tlie  irregu- 
lar, stretched,  burn-like  cicatrices  of  lupus,  and  not  the  round,  de- 
pressed, white  scars  of  syphilis. 

7.  The  scales  on  the  cicatrices,  and  on  the  patches  of  scaly  syph- 
ilitic eruptions,  are  thin,  white,  non-adherent,  lamellar,  very  dill'erent 
from  the  dense,  thick,  imbricated,  adherent  scales  of  psoriasis. 

8.  The  scabs  formed  on  syphilitic,  ulcerative,  rupial,  and  pustular 
lesions  are  rough  and  adherent,  dark-colored,  of  a  greenish  black,  some- 
times loosened  by  an  underlying  accumulation  of  pus,  but  more  often 
seemingly  set  into  the  skin,  and  tightly  adherent.  They  may  be  of 
light  color  where  the  lesion  has  been  pustular,  but,  light  or  dark,  the 
green  shade  is  rarely  totally  absent,  and  is  often  brilliantly  marked. 

9.  Characteristics  of  Ulcers. — With  the  exception  of  the  chancre 
and  of  the  ulcerated  mucous  patch  (both  of  which  may  vegetate,  and 
are  always  liable  to  be  elevated  instead  of  depressed),  the  ulcerations 
of  syphilis  resemble  chronic,  indolent  ulcers.  They  are  rounded  or 
oval,  with  abrupt  edges  cut  away  like  those  of  a  chancroid ;  the  base  is 
covered  with  the  yellowish,  false-membranous-looking  deposit,  some- 
times bluish,  like  boiled  sago.  The  edges  and  base  of  the  ulcer  are 
usually  hard,  and  the  former  generally,  but  not  invariably,  firmly  ad- 
herent, and  not  undermined  as  in  the  ulcerations  of  scrofula.  These 
ulcers  do  not  bleed  easily,  are  generally  atonic  and  sluggish,  and  usu- 
ally entirely  painless.  Apparent  exceptions  to  the  rule  in  regard  to 
pain  are  often  due  to  the  dependent  position,  or  other  cause  sufficient  to 
excite  inflammation,  or  to  the  situation  of  the  ulcer  over  a  bone,  the 
periosteum  of  which  latter  is  suffering  from  painful  syphilitic  disease. 

10.  The  cicatrices  of  such  syphilitic  lesions  as  have  destroyed  tis- 
sue, whether  there  has  been  any  surface  ulceration  or  not,  are  generally 
rounded,  very  thin,  depressed,  smooth,  shining,  and  non-adherent. 
They  are  usually  at  first  uniformly  pigmented,  of  a  coppery  hue,  more 
or  less  deei^  (nearly  black  in  brunettes).  This  pigment  clears  off  from 
the  center  to  the  circumference  until  only  a  dark  border  is  left,  which 
sometimes  lasts  for  months,  but  finally  the  whole  cicatrix  acquires  al- 
most a  pearly  whiteness.  Cicatrices  over  bone  may  adhere  if  they  have 
been  connected  with  bone  lesions.  The  cicatrices  left  by  an  ulceration 
partaking  of  the  nature  of  both  syphilis  and  scrofula  are  often  com- 
plex, that  is,  a  scar  irregular,  uneven,  bridled  on  its  surface,  contracted 
in  parts,  not  much  pigmented,  perhaps  with  a  vein  running  across  it, 
and  often  adherent  at  points  ;  possessing,  in  a  word,  some  of  the  char- 
acters of  a  strumous  cicatrix  added  to  those  due  to  syphilis.  These 
complex  cicatrices  are  best  marked  about  the  neck,  where  glands  have 
suppurated  on  strumous  subjects  w^ho  are  also  syphilitic,  and  are  not 
very  uncommon  after  rupia. 


544  SYPHILIS. 

COXCOMITANT  SYMPTOMS  OF  SECONDARY  SYPHILIS. — The  pllCnom- 

cua  which  most  frequently  precede  or  accompany  the  first  cutaneous 
outbreaks  are  sypliihtic  fever,  indolent  engorgement  of  the  lympliatic 
glands,  headache,  osteocopic  pains,  alopecia,  and  sore-throat,  with  mu- 
cous patches,  and  perhaps  iritis.  A  few  words  will  serve  to  describe 
these  symptoms.     They  follow  the  period  of  secondary  incubation. 

SECONDAilY   INCUBATION. 

Primary  incubation  (as  already  described)  extends  from  the  moment 
of  suspicious  contact  to  the  appearance  of  the  chancre.  Then  primary 
syphilis  is  ushered  in  ;  but  now  there  is  another  period  of  rest,  wherein 
the  disease  seems  to  be  purely  local,  for  there  are  no  general  symptoms. 
This  period  dates  from  the  appearance  of  the  chancre  to  the  appear- 
ance of  general  symptoms.  It  invariably  exists  whether  treatment  be 
commenced  or  not,  and  has  been  named  the  period  of  secondary  incu- 
bation. Primary  syphilis  may,  and  often  does,  extend  through  this 
whole  period,  and  even  longer,  but  still  it  is  a  j^eriod  of  incubation, 
for  the  general  organism  shows  no  sign  of  suffering  until  a  lapse  usu- 
ally of  many  days.  The  shortest  length  of  period  of  secondary  incu- 
bation yet  reported  is  twelve  days  (Gibcrt  and  Rollet)  ;  that  is,  twelve 
days  elapsed  after  the  appearance  of  the  chancre  before  any  general 
symptoms  became  evident.  Rollet  observed  it  again  of  one  hundred 
and  thirty  days' duration.  Diday*  observed  one  case  in  which  the 
secondary  incubation  was  one  hundred  and  sixty  days  ;  the  patient  had 
also  inflammation  of  the  lungs.  Bassercau  saw  an  incubation  of  five 
months,  and  Ricord  puts  down  its  greatest  possible  limit  at  six  months. 
The  mean  length  of  the  period  is  forty-six  (Diday)  or  forty-seven 
(Rollet)  days,  as  established  both  by  experiment  and  clinical  experi- 
ence. This  period  may  often  be  lengthened  materially  by  the  inter- 
vention of  early  treatment,  but  even  then  it  is  customary  for  some 
slight  eruptive  disturbance  to  appear  about  six  weeks  after  the  advent 
of  chancre. 

It  must  not  be  forgotten  that  the  entire  secondary  period  may  be 
skipped,  the  disease  first  appearing  in  its  tertiary  form.  This  state  of 
affairs  may  appropriately  be  termed  delayed  syphilis.  I  have  seen  a 
number  of  such  cases  in  Avhich  I  have  treated  the  patient  myself,  and  no 
eruption  or  evidence  of  syphilis  has  appeared  after  the  first  glandular 
post-cervical  or  epitrochlear  enlargement  has  come  to  confirm  diagno- 
sis— until  after  the  lapse  of  several  years.  I  have  had  one  striking 
case  in  which  I  treated  the  suspicious  sore,  but  could  not  make  up 
my  mind  that  it  was  syphilitic.  I  waited  in  vain  for  confirmatory 
symptoms,  giving  no  treatment.  These  first  appeared  in  the  fourth 
year  as  an  ulcer  (tertiary)  in  the  throat  and  nose,  attended  with  loss  of 
*  "  Ann.  de  Derm,  et  de  Syph.,"  January,  1880,  p.  44. 


SYPHILITIC  TEVER.  545 

bone.  I  have  seen  other  patients  who  after  an  alleged  8oft  chancre 
(not  treated  internally)  have  stated  to  me  that  there  were  no  symptoms 
of  syphilis  until  many  years  later,  when  they  have  applied  to  me  for 
the  treatment  of  tertiary  lesions,  giving  me  the  foregoing  history. 
These  cases  of  delayed  syphilis  or  suppressed  disease  do  certainly  occur, 
but  they  are  not  at  all  common.  Their  consideration  must  necessarily 
be  omitted  in  computing  the  length  of  the  period  of  secondary  incuba- 
tion. The  latter  is  on  an  average  Just  over  six  weeks,  the  first  incuba- 
tion just  over  three,  making  the  habitual  average  appearance  of  the 
first  eruption  after  suspicious  sexual  contact  about  ten  weeks. 

SYPHILITIC   FEVER. 

About  a  week  or  more  before  the  appearance  of  any  eruption,  while 
the  chancre  is  perhaps  showing  signs  of  getting  well,  the  patient  is 
liable  to  exhibit  more  or  less  marked  symptoms  of  fever,  but,  as  in 
nearly  all  of  the  symptoms  of  syphilis,  so  in  this  one,  the  intensity  va- 
ries in  different  cases  from  nothing  upward.  The  poison  of  syphilis  is 
at  work  during  the  period  of  secondary  incubation,  and  produces  more 
or  less  cachexia  by  directly  diminishing  the  quantity  of  the  red  cor- 
puscles of  the  blood.  In  1844  Grassi,*  the  enterprising  apothecary  of 
the  Hotel  Dieu,  by  frequently  repeated  analyses  found  this  diminution 
of  the  red  corpuscles  to  vary  in  different  cases  from  eleven  to  sixty-five 
per  cent,  and  noted  also  that  the  percentage  of  corpuscles  increased 
under  the  administration  of  the  iodide  of  potassium.  Wilbouchewitch,f 
by  counting  under  the  microscope,  found  that  syphilis  produces  ane- 
mia directly,  reducing  the  number  of  the  red  blood-cells.  He  decided 
that  the  use  of  mercury  in  small  doses  increased  the  number  of  red 
cells  under  these  conditions  for  a  time,  but  persisted  in  diminished 
them.  I  X  investigated  the  subject  personally  later,  and  found  that 
syphilis  does  reduce  the  number  of  the  red  blood-cells,  that  the  con- 
tinued use  of  a  small  dose  of  mercury  (which  I  have  named  the  "tonic 
dose")  arrests  the  diminution  and  causes  an  increase  of  the  red  cells, 
and  that  this  tonic  dose  may  be  persisted  in  indefinitely — as  far  as  I 
have  investigated,  over  five  years — without  losing  this  tonic  effect  and 
power  of  increasing  the  number  of  the  red  cells  and  maintaining  them 
in  their  increased  proportion.  In  early  syphilis  some  diminution  of 
the  red  corpuscles  seems  to  be  constant ;  bat,  while  it  varies  greatly  in 
cases  where  no  treatment  has  been  employed,  under  early  judicious 
treatment  the  amount  of  decrease  is  certainly  less.  This  syphilitic 
hydraemia,  then,  is  constant,  but  it  may  be  so  slight  as  not  to  be  ac- 

*  Ricord,  "Lemons  sur  le  Chancre,"  1860,  p.  1S9,  2cl  edition,  edited  by  Fournier. 
f  "Archives  de  Physiologie,"  Browa-Sequard,  1874.  p.  516. 

:j:  "Treatment  of  Syphilis,"  etc.,  "Trans.  Internatiooal  Medical  Congress,"  Philadel- 
phia, 1877,  p.  726. 


540  SYPHILIS. 

compauicd  b\-  any  observable  fever  ;  while,  again,  tlie  amount  of  febrile 
disturbance  may  be  considerable.  Hence  it  sometimes  ajipears  that 
syphilitic  fever,  as  such,  is  entirely  absent.  Lancereanx  believes  that 
it  is  present  in  two  thirds  of  all  cases.  When  present  as  distinct 
fever,  it  is-marked  by  physical  and  mental  depression,  loss  of  appetite, 
functional  disturbance  of  the  jirimiv  via\,  and  a  temperature  running 
up  in  the  evening,  according  to  Cnntz,*  sonu'times  to  nearly  104° 
Fabr,,  but  falling  again  rapidly  after  a  few  days.  As  a  rule,  it  does 
not  get  so  high. 

The  fever  may  be  continuous,  or  may  occur  in  paroxysms,  chiefly 
toward  night,  followed  by  sweating.  The  type  of  the  fever  may  be 
also  remittent,  or  even  occasionally  intermittent,  Avith  regular  tertian 
paroxysms  of  chill  and  fever.  Again,  the  fever  may  be  low  and  typhoid 
in  ty]ie.  The  spleen  is  occasionally  enlarged  in  cases  of  this  fever,  says 
Baiimler.f  I  have  not  yet  observed  it,  Fournier  has  not  seen  it, 
Schuster  J  met  it  once. 

Sometimes  it  is  accompanied  by  nausea,  hebetude,  and  stupor  ;  or, 
again,  the  jxatient  may  feel  quite  comfortable  and  as  well  as  usual, 
retaining  his  appetite,  or  even  eating  more  than  his  ordinary  amount 
of  food — bulimia  (Fournier).  Whether  there  be  much  or  little  true 
fever,  the  hydraemia  commonly  announces  itself  by  sallowness  of  the 
comjilexion,  with  pallid  face,  pinched  features,  and  sunken  eyes.  The 
nervous  depression  is  sometimes  prominent,  occasioning  melancholy, 
with  sad  looks,  a  gloomy  view  of  life,  even  to  a  tendency  to  suicide. 
The  patient  exaggerates  his  sufferings,  and  is  often  wofully  depressed, 
complaining  of  general  malaise,  fatigue,  and  feebleness.  Parox3-smal 
or  continued  neuralgia,  vertigo,  feelings  of  faintness,  may  come  on  ; 
these  perhaps  spontaneous,  or,  again,  provoked  by  movements  of  the 
head.  Where  the  hydrgemia  is  marked,  shortness  of  breath  is  com- 
plained of,  and  palpitation  ;  a  soft,  blowing  sound  may  be  heard  at  the 
base  of  the  licart  and  in  the  vessels  of  the  neck.  Epistaxis  and  oedema 
of  the  feet,  perhaps,  occur,  and  tenderness  or  swelling  of  the  joints. 

With  or  without  these  symptoms  of  hydrasmia,  pain  is  almost  con- 
stant in  syphilitic  fever  and  during  the  earlier  eruptions.  This  pain 
usually  affects  the  fibro-osseous  system,  and  is  known  as  osteocojiic 
(oo-Teov-KOTTTetv,  lone-hreahmg),  on  account  of  its  peculiar  intensity.  It 
assumes  a  multitude  of  forms,  occurring  in  the  nucha,  back,  loins,  be- 
tween the  ribs,  constituting  a  pleurodynia  sometimes  mistaken  for 
pleurisy,  in  the  shoulders,  elbows,  knees,  and  sternum  (Baglivi). 
These  pains  are  movable  sometimes,  shifting  rapidly  from  one  part  to 
another.  They  may  occur  only  at  night,  or  may  be  continuous,  in 
which  case  they  are  often  decidedly  worse  at  night.     Pressure  some- 

*  "Das  syphilitische  Ficber,"  Leipzig,  1873. 

f  V.  Ziemssen's  "Cyclopaedia  of  Medicine,"  art.  "Sypliilis." 

%  "Archives  f.  Derm.  u.  Syph.,"  1873,  p.  283. 


SYPHILITIC   FEVER— TREATMENT.  547 

times  affords  them  temporary  relief,  or,  on  the  other  hand,  evokes 
them  where  they  are  not  spoutaneous.  A  diagnostic  value  has  been 
attached  to  the  fact  that  pressure  over  the  lower  or  upper  third  of  the 
sternum  produces  pain  not  otherwise  complained  of.  Among  the 
pains  of  early  syphilis,  headache  is  prominent,  often  of  an  excruciat- 
ing character  and  usually  worse  at  night.  The  joints  may  stiffen  and 
be  hard  to  move,  on  account  of  pain.  Effusion  occasionally  occurs  in 
and  around  them,  giving  to  syphilitic  fever  the  aspect  of  mild  acute 
inflammatory  rheumatism.  Jaundice  with  accelerated  pulse  may 
come  on  during  or  just  before  the  eruption,  rarely  lasting  over  a  few 
weeks,  and  due  to  hepatic  engorgement,  or,  possibly,  as  Lancereaux 
suggests,  to  compression  of  the  bile-duct  by  enlarged  lymphatic  glands, 
since  this  cause  is  certainly  sufficient  to  produce  icterus  occasionally 
in  advanced  syphilis.  The  pulse  of  syphilitic  fever  rarely  reaches 
higher  than  120°.  The  fever  is  usually  greater  according  as  the  erup- 
tion is  early  and  abundant.  Sometimes  it  quickly  abates  and  disap- 
pears as  the  eruption  comes  out,  or  it  may  continue  and  get  worse  for 
weeks.  Occasionally  there  are  some  slight  feverish  symptoms  just  be- 
fore other  crops  of  eruptions  which  succeed  the  first  general  outbreak. 

The  diagnosis  of  syphilitic  fever  is  made  by  a  study  of  the  history 
of  the  case. 

Treatment  is  mainly  tonic  and  hygienic ;  these  means  being  per- 
sistently pushed  while  the  general  treatment  of  syphilis  is  kept  up. 
Anodynes  are  sometimes  required  to  master  the  pains.  Although 
Grassi  found  that  the  number  of  red  blood-corpuscles  did  not  increase 
under  the  administration  of  mercury,  the  explanation  plainly  is,  that 
in  those  days  mercury  when  used  was  given  in  heavy,  and  not  in  tonic 
doses,  and  my  researches  show  *  that  such  a  mercurial  course  directly 
induces  antemia  and  reduces  the  number  of  the  blood-cells.  Indeed, 
modern  authors  are  in  accord  in  deciding  that  mercury  is  the  coiTect 
treatment  for  syphilitic  fever  and  the  early  syphilitic  osteocopic  pains. 
Quinine  has  no  value  in  reducing  temperature  in  this  fever  or  curing 
the  attack. 

In  inherited  disease  there  appears  to  be  no  fever.  Holm  f  found 
in  some  Copenhagen  children  that  the  temperature  in  the  period  of 
eruption  ranged  below  the  normal,  while,  in  the  cases  of  some  children 
with  acquired  disease,  the  temperature  was  normal  or  with  a  slight 
evening  rise.  There  seems  to  be  no  reason  for  this,  and  I  think  con- 
firmation is  needed  before  the  report  is  generally  adopted. 

A  few  words  will  suffice  for  the  other  ordinary  concomitants  of  the 
earlier  general  syphilides,  alopecia,  general  indolent  glandular  engorge- 
ment, sore-throat,  iritis,  mucous  patches,  paralysis,  anaesthesia,  anal- 
gesia, bulimia,  jaundice. 

*  "Trans.  International  Med.  Congress,"  ]8v7. 

f  Referred  to  by  Hill  and  Cooper.     Second  edition,  p.  109. 


548  SYPHILIS. 


ALOPECIA. 


Falling  of  tlic  liair  due  to  syphilis  is  of  two  kinds.  Wlicre  there 
are  scabby  sores  on  the  :?calp.  and  especially  in  later  iilcerative  disease, 
the  hair-follicles  over  limited  areas  become  destroyed,  in  which  case 
the  fallen  hair  is  not  reproduced.  Ordinarily,  however,  general  bald- 
ness occasioned  by  syphilis  is  only  temporary.  In  fact,  baldness  is  not 
usually  produced,  but  only  a  considerable  thinning  of  the  hair  gener- 
ally, or  in  mottled  patches,  not  only  of  the  scalp,  but  of  the  eyebrows, 
eyelids,  whiskers,  and,  to  a  degree,  of  the  whole  body.  Alopecia  is 
sometimes  complete  over  the  entire  body.  More  or  less  local  alopecia 
is  sometimes  met  with  (on  the  fron to- temporal  region)  in  cases  of  in- 
herited syphilis  (Barlow,*  Parrot  f). 

In  acquired  syphilis  the  thinning  of  the  hair  is  due  to  one  of  two 
causes  (that  is,  when  there  is  no  eruption  or  ulceration  involving  the 
hair  pai)ilUv)  : 

(1)  The  syphilitic  hydrremia,  which,  like  thin-bloodedness  from  any 
other  acute  cause  (fever),  temporarily  impairs  the  vitality  of  the  hair- 
papilla?,  causing  the  hair  to  lose  its  luster  and  then  to  fall  out. 

(2)  A  seborrho^a,  the  sebaceous  matter  clogging  the  hair-follicle, 
pressing  upon  the  papilla,  ultimately  leading  to  the  fall  of  the  hair, 
and  possibly,  in  some  cases,  to  the  atrophy  of  the  papilla.  The  dried 
sebaceous  matter  mixed  with  scales  may  usually  be  scraped  away  jolen- 
tifully  from  the  scalp  around  the  hairs. 

Treatment. — Although  some  falling  off  of  the  hair  is  often  inevita- 
ble, yet  the  cpiantity  may  be  lessened  by  attention  to  the  hygiene  of 
the  scalp,  shampooing  once  a  week  with  ammonia  or  borax  in  warm 
water  (a  teaspoonful  to  the  pint)  to  get  rid  of  the  accumulating  seba- 
ceous matter,  and  the  use  afterward  of  a  stimulating  lotion,  of  which 
a  little  may  be  rubbed  upon  the  scalp  nightly.  One  of  the  best  of 
these  is  : 

5      Tr.  capsici,  3  ij-v. 

Glvcerini,  3  j- 

Aqua)  Colognicnsis,  ad  3J.     M. 

"Where  sores  infest  the  scalp,  general  treatment  alone  is  to  be  relied 
upon. 

INDOLENT    GLANDULAR    ENGORQEMEl^T. 

Coincidently  with  the  first  outbreak  of  general  syphilis,  sometimes 
preceding  the  eruption,  more  often  shortly  following  it,  there  is  a 
marked  tendency  to  a  general  indolent  engorgement  of  the  lymphatic 
glands.  This  concomitant  symptom  rarely  fails,  and  it  furnishes  a 
diagnostic  mark  of  the  first  importance  in  all  doubtful  cases.     The 

*  "Lancet,"  August  22,  1877.  f  "Progr^s  Medical,"  1878,  No.  22. 


SOKE-TIIROAT.  549 

enlargement  of  the  glands  does  not  necessarily  depend  upon  the  occur- 
rence of  an  eruption,  since  it  is  encountered  where  close  observation 
fails  to  detect  any  neighboring  cxanthcm.  This  is  particularly  true 
of  the  post-cervical  and  epitrochlear  glands.  The  engorgement  of  the 
glands  is  indolent,  painless.  They  are  usually  of  a  cartilaginous  hard- 
ness, insensitive  to  pressure,  varying  in  size  from  a  small  pea  to  a 
marble. 

The  coincident  indolent  engorgement  of  certain  glands  is  almost 
pathognomonic  of  syphilis.  These  are  the  post-cervical  (posterior 
chain),  markedly  two  little  glands  lying  high  up  on  either  side  of  the 
nucha,  upon  the  occipital  bone  ;  a  gland  over  the  mastoid  process  of 
the  temporal  bone  ;  and  the  epitrochlear  gland  (or  glands)  on  either 
side,  just  above  and  without  the  inner  condyle  of  the  humerus.  Other 
glands  may  also  become  indolently  engorged,  but  more  rarely  ;  as,  the 
lateral  or  the  cervical,  the  axillary,  the  inguinal  (where  the  chancre  is 
extragenital,  and  where  these  glands  consequently  have  escaped  pri- 
mary infection) ;  but  the  glands  of  most  assistance  to  diagnosis  are 
undoubtedly  the  post-cervical  and  epitrochlear,  and  these  should  be 
sought  for  in  all  cases  to  confirm  the  diagnosis  of  general  syphilis. 

SORE-THROAT. 

Sore-throat  is  a  concomitant  symptom  of  all  stages  of  general  syphi- 
lis.    There  are  three  type  varieties  : 

1.  A  diffuse  general  redness,  with  or  without  ulceration. 

2.  A  certain  amount  of  chronic  congestion,  and  brawny  thickening 
about  mucous  patches  or  atonic  ulcers. 

3.  Destructive  ulceration  from  gummy  deposit. 

The  first  variety  is  an  early  secondary  phenomenon,  and  alone  of 
the  three  is  a  concomitant  of  the  early  syphilides ;  the  second  may 
occur  along  with  the  later  secondary  and  earlier  tertiary  lesions  ;  the 
third  is  tertiary.  They  will  be  described  in  connection  with  the  other 
symptoms. 

Eecently  Fournier  *  has  noted,  as  a  concomitant  symptom  of  the 
earlier  secondary  period  of  syphilis,  certain  aberrations  of  cutaneous 
sensibility,  such  as  loss  of  ordinary  cutaneous  sensitiveness  (ausesthe- 
sia),  inability  to  appreciate  the  sensations  of  heat  and  cold,  and  com- 
plete insensitiveness  to  pain  (analgesia)  ;  these  either  general  or  more 
commonly  confined  to  limited  areas  of  skin,  notably  the  extremities. 
The  back  of  the  hand  over  the  wrist  is  a  favorite  location.  The 
trouble  is  a  passing  one,  not  lasting  more  than  a  few  months,  and  has 
been  observed  by  Fournier  chiefly  in  women.  It  is  questionable 
whether  hysteria  may  not  often  play  a  prominent  part  in  the  causa- 

*  "Annales  de  Dermatologie  et  de  Syphilographie,"  tome  i,  1869,  p.  4S6.      "Sur  la 
Syphilis,"  Paris,  1873. 


550  GENERAL  TKEATMENT  OF  SYPrilLIS. 

tion  of  these  phenomena.     Fonrnier's  observations  include  over  a  hun- 
dred cases. 

Iritis  conchiucs  the  group  of  concomitant  symptoms.     It  will  bo 
described  later. 


CHAPTEK  V. 

OENERAL   TREATMENT  OF  SYPHILIS. 

Hygienic,  Tonic,  Specific  Trentineiit.—Syphilization.— Treatment  of  Early  Syphilis.— Bad  Efifects  of 
Mercury.— Method!?  of  administering  Mercury.- Treatment  of  Late  Syphilis.— Mixed  Treatment. 
—Treatment  by  the  Iodides.— Methods  of  administering  Iodine  in  Syphilis.— Quantity  of  Iodide 
which  may  be  required.— Duration  of  General  Treatment. 

The  general  *  treatment  of  syphilis  is  hygienic,  tonic,  and  specific. 
The  latter  is  often  inelfective  unless  aided  by  the  former.  Neither 
should  be  depended  upon  alone.  They  form  component  parts  of  one 
rational  system. 

Hygienic  Treatment. — The  hygienic  treatment  of  syphilis  includes 
all  the  ordinary  laws  of  health.  Eegularity  of  the  habits — especially 
of  those  of  eating  and  sleeping,  and  of  those  involved  iu  the  perform- 
ance of  intestinal  functions — is  all-important.  No  deviations  need  be 
made  from  ordinary  diet.  Excesses  of  any  kind  are  bad,  even  emo- 
tional (fear,  anger),  and  especially  excesses  in  strong  drink,  in  work, 
in  venery.  The  function  of  the  skin  should  receive  attention  through 
scruiDulous  cleanliness.  Warm  baths  are  more  cleanly  and  relaxing  to 
the  skin  than  cold.  If  baths  be  too  hot  early  in  the  disease,  they  are 
apt  to  call  out  a  more  plentiful  crop  of  eruption.  Catching  cold  should 
be  avoided.  It  is  apt  to  induce  and  prolong  mucous  and  ulcerative 
patches  about  the  mouth,  nose,  and  throat.  Singing,  and  loud  and 
continuous  talking,  are  objectionable  in  subjects  having  weak  throats. 
Experience  has  taught  that  tobacco  in  all  forms,  and  even  highly- 
seasoned  food,  is  certainly  injurious,  in  irritating  and  keeping  up  an 
outcrop  of  mucous  patches.  Air,  exercise,  and  light,  essentially  neces- 
sary to  all  animal  well-being,  are  particularly  so  in  the  case  of  obsti- 
nate chronic  or  advancing  disease.  Change  of  air  in  some  of  these 
cases  is  essential  to  the  success  of  treatment,  as  a  trip  to  the  country, 
change  from  tiie  seaboard  to  the  mountains,  or  from  inland  to  the 
shore,  and  then  perhaps  back  again,  six  weeks  being  usually  long 
enough  in  any  locality  to  obtain  its  maximum  effect  for  good. 

I  have  more  than  once  observed,  when  I  could  not  so  manage  it 
with  a  patient  in  New  York  that  his  stomach  could  be  made  to  toler- 

*  The  local  and  special  means  rcfiuircd  for  the  difTercnt  manifestations  of  the  disease 
will  be  detailed  under  the  heads  of  the  symptoius  requiring  them. 


HYGIENIC   AND   SPECIFIC   TREATMENT.  551 

ate  a  high  enough  dose  of  the  iodide  of  potassium  to  control  liis  lesions 
(this  notably  in  tertiary  conditions),  that  a  few  days  in  tlie  country 
would  so  hold  the  patient  up  that  he  could  take  his  dose,  and  that  his 
symptoms  would  promptly  change  for  the  better.  I  have  noticed  the 
same  fact  in  connection  with  patients  sent  to  me  from  Chicago  and 
elsewhere  ;  they  could  with  ease  and  advantage  tolerate  heavier  medi- 
cation in  New  York  than  at  home.  The  rule  is  positive.  Many  ob- 
stinate bad  cases  of  late  secondary  and  tertiary  disease,  which  fail  to 
respond  to  treatment  in  their  homes,  especially  if  that  home  be  in  the 
city,  make  rapid  strides  toward  recovery  as  soon  as  the  air  and  sur- 
roundings have  been  modified.  Mercury  and  the  iodides  will  not  cure 
all  syphilis,  as  many  practitioners  seem  to  believe.  The  old  chronic 
cases,  remaining  from  year  to  year  in  our  large  hospitals,  and  relapsing 
endlessly  in  the  damp  and  crowded  tenements  of  our  large  cities,  are 
not  in  need  of  medical  treatment,  for  this  they  have  and  of  the  best ; 
but  what  they  need  is  intelligent  hygiene,  and  with  its  assistance  many 
of  them  would  recover. 

In  the  hygienic  category  naturally  belongs  all  tonic  and  supportive 
medication.  Cod-liver  oil,  iron,  quinine,  and  all  lesser  helps,  find 
ample  space  to  vindicate  their  claims  at  some  part  of  the  treatment  of 
most  cases.  Without  them  specific  treatment  is  often  unworthy  the 
name.  In  the  hydrsemic  stage.  Just  before  and  during  syphilitic  fever 
and  the  earlier  exanthemata,  as  well  as  during  portions  of  the  later 
cachexige,  these  remedies  are  of  the  greatest  value,  and  may  occasion- 
ally be  used  alone  with  advantage  until  the  general  tone  of  the  patient 
can  be  elevated  ;  after  which  the  prompt  efficiency  of  the  specifics,  in- 
telligently administered,  gives  them  a  claim  to  the  title  of  being  the 
most  reliable  drugs  used  in  the  practice  of  medicine.  There  are,  how- 
ever, certain  phases  of  syphilitic  cachexia  over  which  no  tonics  act 
with  the  same  efficiency  as  minute  doses  of  mercury,  especially  corro- 
sive sublimate,  in  women  preferably  combined  with  iron. 

Specific  Treatment  of  Syphilis. — But  few  known  remedies  have 
been  left  untried  in  the  treatment  of  syphilis.  Besides  the  old-fashioned 
sarsaparilla,  guaiac,  mezereou,  stillingia,  cundurango,  and  a  host  of 
other  vegetable  remedies,  we  have  in  these  modern  days  cascara  amar- 
ga,  tuyuya,  the  vegetable  combination  suggested  by  Simms,  called 
succus  alterans,  and  many  other  inferior  and  purely  quackish  reme- 
dies. The  claims  of  few  of  these  need  detain  us.  Most  of  the  syphi- 
lides,  especially  the  earlier  varieties,  are  self-limiting,  and  will  get 
well  under  any  treatment — one  might  even  say  in  spite  of  treatment. 
Mild  cases,  especially  in  married  women,  often  go  untreated,  unrecog- 
nized indeed,  and  the  patients  never  suffer  any  considerable  incon- 
venience. It  is  on  cases  of  this  order  that  anti-mercurialists  build  their 
theories,  substantiating  the  latter  by  reference  to  cases  in  themselves 
inveterate  and  malignant  in  spite  of  the  use  of  mercury,  or  perhaps  in 


552  GENERAL  TREATMEXT  OF  SYPniLIS. 

connection  with  it?  improper  use.  No  treatment  may  be  better  than 
overtroatmcnt.  Indeed,  the  lesions  often  get  well  spontaneousl}' upon 
the  advent  of  some  other  malady.*  This  seems  to  be  especially  true 
of  erysipelas.  Ch.  Mauriac,f  in  a  monograph,  maintains  that  erysipe- 
las acts  updn  syphilis  in  a  general  as  well  as  in  a  local  way,  lesions  get- 
ting well  which  are  never  touched  by  the  erysipelatous  redness,  but 
less  promptly  as  they  are  more  distant. 

The  different  vegetable  decoctions  and  infusions,  of  which  sarsa- 
parilla  takes  the  lead,  assist  digestion,  promote  the  action  of  the  skin, 
encourage  the  functional  activity  of  the  kidney,  and  please  the  patient. 
They  may  be  adjuvants  in  certain  cases,  and  should  be  perhaps  ranked 
along  with  hygienic  and  tonic  means,  but  they  have  not  merited  by 
their  action  any  right  to  the  term  curative  in  its  narrowest  sense,  since 
they  do  not  demonstrably  postpone  relapses  or  shorten  the  duration  of 
existing  symptoms  any  more  tlian  other  hygienic  and  tonic  means.  I 
think  it  is  not  doubtful  that  Zittmann's  decoction  is  a  remedy  of  posi- 
tive value,  especially  in  late  syphilis,  when  there  is  cachexia,  ana?mia, 
irritable  stomach,  loss  of  appetite,  moderate  constipation,  and  particu- 
larly when  the  stomach  will  not  take  the  iodides  kindl3\  The  senna 
encourages  intestinal  action,  the  sarsaparilla  undoubtedly  has  an  influ- 
ence, because  if  left  out  the  remedy  is  decidedly  less  effective,  and  the 
mercury  is  presented  in  a  suitable  way  to  exercise  its  tonic  effect. 
But  the  old-fashioned  Zittmann's  decoction  was  full  of  unnecessary 
ingredients  in  its  composition,  and  was  troublesome  to  make,  difl&cult 
to  take  on  account  of  the  quantity  required  as  a  dose,  and  its  adminis- 
tration was  surrounded  by  unnecessary  rules  and  precautions.  Start- 
ing with  the  original  decoction,  and  then  modifying  it  by  McDonnell's 
formula,  I  have  gradually  dropped  one  thing  after  another  until  I  have 
now  come  to  use  (often  with  decided  advantage  in  cachectic  cases  of 
old  syphilis  needing  a  tonic  course)  the  following  formula,  of  which  I 
usually  order  a  tablespoonful  to  be  taken  several  times  a' day,  regulat- 
ing the  dose  somewhat  according  to  the  purgative  effect : 

5     Eydrarg.  chlorid.  corros.,  gr.  j. 

Alumiuis,  3  ss. 

Ext.  sarsaparillaj,  o  ^j- 

Glycerin,  1  j- 

Syr.  senna?,  '  3  j^^- 

Spts.  anis.,  3  j- 

Extr.  glycyrrbizaj,  3  j- 
Aquae  foeniculi,                                                    q.  s.  ad  =  viij.     M. 

I  have  not  found  the  advantage  in  pilocarpine  wliich  it  has  been 
suggested  it  would  afford. 

As  to  the  succus  altcrans  alone,  I  am  sure  it  is  unnecessary  in  sec- 

■"  Pctrowsky,  referred  to  in  "Medical  Record,"  May  6,  1882,  p.  487. 

f  "Etude  clinique  sur  riufluence  curative  de  I'erysipule  dans  la  Syphilis,"  Paris,  1873. 


SYnilLIZATION.  558 

ondary  syphilis,  and  powerless  in  tertiary.  I  liaye  seen  the  ravages  of 
tertiary  ulcerative  disease  go  on  unchecked  for  months  under  its  ex- 
hibition in  wine-glassful  doses,  at  the  hands  of  another  practitioner. 
That  it  may  not  be  of  some  service  in  combination  with  the  more  po- 
tential drugs,  I  can  not  state  ;  I  have  heard  reputable  gentlemen  say 
that  they  thought  it  was.  I  have  not  observed  the  fact,  although  I 
have  tested  the  combination  largely.  In  any  case  tlie  quackish  and 
pretentious  manner  in  which  the  medicine  is  being  forced  upon  the 
profession  is  enough  to  condemn  it,  and  to  make  any  honest  man 
doubt  its  claims.  That  it  does  no  good,  I  can  not  affirm.  That  it 
does  what  it  pretends  to  do  is  false,  in  my  opinion. 

SypMlizat'ion  has  long  since  been,  judged  and  discarded. 

The  preparations  of  gold  and  copper  can  not  be  at.  all  depended 
upon,  and  the  bichromate  of  jiotassium  *  certainly  does  not  do  in  this 
country  what  has  been  claimed  for  it  in  Europe. 

The  Hot  Springs  of  Arkansas  require  a  word  of  serious  comment 
here.  That  they  have  a  positive  value,  I  am  sure.  I  visited  the 
springs  a  few  years  ago,  and  remained  there  long  enough  to  see  their 
workings.  I  have  sent  many  patients  there,  have  deterred  many  others 
from  going,  and  seen  patients  in  all  stages  of  syphilis  who  had  been 
to  the  springs  before  their  first  visit  to  me.  From  such  premises  I 
think  I  may  reach  conclusions  which  shall  be  reasonably  just.  The 
physicians  who  practice  at  the  springs  are  not  in  accord  as  to  the  spe- 
cial property  of  the  waters  which  gives  them  their  value.  Some  think 
that  the  water  is  like  any  other  hot  water,  and  that  jaatients  do  well 
at  the  springs  simply  because  tbey  come  there  determined  to  take  care 
of  themselves,  and  to  make  the  treatment  of  their  malady  their  first 
object.  True  it  is  that  the  waters  are  almost  void  of  any  mineral  in- 
gredient. The  waters  of  the  so-called  old  Iron  Spring  (I  think  it  is 
called  so  because  the  house  erected  over  it  is  made  of  corrugated  iron, 
and  not  because  of  any  iron  in  its  water)  deposit  a  tufa  which  clings 
in  masses  to  the  hill  out  of  which  the  spring  flows,  but  I  am  informed 
that  the  actual  mineral  contents  of  the  water  is  only  about  eight  grains 
to  the  gallon,  which  is  practically  nothing.  Lime  seems  to  be  the 
main  ingredient.  The  water  of  this  spring  is  used  at  the  main  hotel 
of  the  place  for  drinking-water,  and  it  is  as  pure,  bright,  sparkling, 
and  tasteless  as  any  water  I  have  ever  seen.  Taken  cold,  it  certainly 
has  no  obvious  effect ;  taken  hot,  it  is  diuretic  and  diaphoretic  more 
positively  than  ordinary  hot  water.     It  does  not  nauseate. 

Others  of  the  local  physicians  impute  the  effect  of  the  waters  to 
something  sui  generis  in  the  quality  of  the  heat  they  contain  ;  others 
ascribe  it  to  silicon,  which  the  water  is  said  to  contain  ;  others  to  elec- 
tricity, in  which  also  the  water  is  said  to  abound.  My  own  investiga- 
tions showed  me  that  a  foot-bath  at  110°  Fahr.  was  impossible.     The 

*  "  Die  Syphilis-Behandlung  ohne  Quecksilber,"  J.  Edmund  Giintz,  Berlin,  18S2. 


554  GENERAL  TPiEATME-NT   OF  SYrniLIS. 

feet  could  not  possibly  be  retained  in  water  of  that  temperature,  a 
thing  perfectly  possible  (but  not  pleasant)  at  home  in  Croton  water, 
A  thermometer  held  in  the  mouth  while  making  the  attempt  to  take 
this  foot-bath  was  raised  to  103°  Fahr.  An  ordinary  bath  at  98°  Fahr. 
was  unpleasantly  hot,  and  caused  the  perspiration  to  trickle  from  the 
face  in  streams.  The  immediate  aftcr-eiToet  of  the  bath  (unlike  that 
of  an  ordinary  hot  bath)  is  one  of  exhilaration,  followed  in  a  couple 
of  hours  by  reaction  and  a  desire  to  sleep.  The  immediate  eilect  of 
the  water  I  found  to  be  stimulating,  not  soothing.  An  inflamed  joint 
soaked  in  this  water  is  harmed  by  it,  and  the  pain  intensified,  con- 
trary to  what  is  experienced  with  ordinary  hot  water  ;  acute  eruptions 
are  said  to  be  aggravated  by  the  water.  This  I  did  not  personally 
have  an  opportunity  of  testing  except  in  a  case  of  generalized  eczema, 
which  certainly  was  aggravated  at  the  hot  springs,  and  began  to  get 
well  at  the  (cold)  sulphur  potash  spring  a  few  miles  away.  Old  chronic 
ulcers,  whether  scrofulous,  s}-philitic,  or  accidental,  are  stimulated 
promptly  into  granulation  by  the  local  effect  of  these  waters.  The 
appetite  im]n-0Tcs  under  their  use,  and  the  ordinary  functions  seem  t,o 
be  performed  better  than  when  they  are  not  used  by  the  visitors  to  the 
place.  The  uterine  function  seems  to  be  stimulated  by  the  baths,  and 
stories  of  a  return  of  menstruation  after  the  change  of  life,  of  impreg- 
nation after  long  sterility,  and  the  like,  arc  told  by  the  natives.  Para- 
lytics, and  peo^ile  recovering  from  apoplexy,  seem  to  thrive  at  the 
springs. 

But  all  this  is  not  the  cure  of  syphilis,  and  my  observation  showed 
me  plainly  that  the  physicians,  who  did  well  at  the  springs  used  most 
unsparingly  mercury  by  inunction,  and  iodide  of  potassium  internally 
in  enormous  doses.  And  this  is  exactly  wherein  the  value  of  the 
springs  seems  to  lie.  Patients  broken  down,  cachectic,  with  faulty 
stomachs,  who  have  syphilitic  lesions  which  fail  to  yield  at  home  be- 
cause they  can  not  tolerate  a  sufficiently  high  degree  of  medication — 
these  are  the  patients  to  send  to  the  hot  springs.  There,  under  the 
assistance  of  the  hot  water  internally  and  the  baths,  they  can  take  a 
mercurial  friction  day  after  day,  without  salivation,  w'hicli  would  over- 
whelm them  at  home,  and  their  doses  of  iodide  of  potassium  can  be 
quadrupled  without  upsetting  the  stomach.  I  have  verified  this  over 
and  over  again.  This  is  the  only  class  of  patients  I  ever  send  to  the 
sj)rings — those  requiring  stiff  medication  for  serious  lesions  who  can 
not  at  home  be  made  to  tolerate  a  sufficiently  high  dose  to  pull  them 
through. 

I  could  multiply  illustrative  cases  of  this  order  almost  indefinitel}'. 
One  i^atient  several  years  ago  I  sent  to  the  springs  under  escort  of  a 
nurse  and  a  relative.  lie  had  been  going  persistently  wrong  by  the 
head  at  my  hands  and  those  of  several  other  physicians.  He  had  had 
several  hemiplegic  attacks,  serious  ocular  troubles,  aphasia,  double 


SYrillLIZATIOX.  555 

vision,  and  mental  derangement.  His  head  was  gone  for  all  purposes, 
and  lie  was  obliged  to  give  up  business  entirely.  No  efforts  of  mine 
or  others  could  by  any  of  tlic  adjuvants,  belladonna,  arsenic,  milk, 
carbonated  waters,  alkaline  waters,  get  the  daily  dose  of  this  patient 
above  three  hundred  grains  of  the  iodide  of  potassium — and  his  symp- 
toms were  gradually  gaining  upon  him  until  his  case  seemed  hopeless. 
Then  he  went  with  difficulty  to  the  springs,  and  there,  with  no  aid  be- 
yond the  use  of  the  waters,  his  daily  dose  of  the  iodides  was  run  up 
to  eight  hundred  grains,  and  under  this  he  recovered,  and  by  after- 
treatment  at  home  became  able  again  to  resume  his  business.  I  have 
had  a  number  of  cases  of  this  sort,  and,  particularly  when  the  brain  and 
cord  are  seriously  involved,  I  advocate  the  hot  spring  at  any  price  in 
money,  time,  or  comfort.  It  is  certainly  worth  while.  But  for  ordi- 
nary syphilis  I  do  not  consider  the  springs  of  any  value.  They  do 
not  shorten  the  duration  of  the  disease,  prevent  relapse,  or  cure  it  in 
any  sense.  The  lesions  of  early  syphilis  disappear  rapidly  under  the 
heavy  medication  administered  at  the  springs,  but  I  do  not  think  there 
is  any  special  value  in  this,  because  it  makes  the  patient  less  willing 
to  take  prolonged  continuous  treatment,  in  which  alone  in  my  opinion 
lies  his  best  hope. 

The  patient  going  to  the  springs  is  almost  invariably  told  that  he 
must  come  back  in  a  year,  and  then  in  another  year,  if  he  wishes  to 
be  cured.  But  no  number  of  courses  guarantees  a  man  against  the 
possibility  of  subsequent  relapse.  Therefore,  I  believe  the  rule  should 
be  :  Send  no  patients  to  the  springs  who  do  well  under  ordinary  medi- 
cation at  home — send  only  the  debilitated,  the  cachectic,  and  those 
afflicted  with  serious  late  lesions  (notably  those  of  the  nervous  system), 
who  have  not  the  stomach  to  bear  at  home  a  sufficiently  high  grade  of 
medication  to  effect  their  cure. 

The  specific  treatment  of  syphilis  consists  in  the  intelligent  adminis- 
tration of  mercury  and  of  some  of  the  preparations  of  iodine.  It  is 
divided,  for  convenience  of  description,  into — 

1.  Treatment  of  early  syphilis  ; 

2.  Treatment  of  late  syphilis — mixed  treatment. 

The  proper  duration  of  treatment  will  be  discussed  at  the  end  of 
the  section. 


1.  TREATMENT   OF   EARLY   SYPHILIS. 

G-eneral  treatment  should  be  commenced  as  soon  as  the  diagnosis 
of  syphilis  is  positive.  To  be  positive  on  such  an  important  point 
requires  more  evidence  than  is  furnished  by  the  simple  physical  char- 
acters of  the  sore,  be  they  ever  so  positive.  Diagnosis  sufficiently  ac- 
curate to  commence  treatment  upon  can  only  be  made  by  confronta- 
tion— establishing  the  syphilitic  disease  in  the  person  from  whom  the 


556  GEXEILVL   TREATMENT   OF  SYnilLIS. 

cliaucre  was  derived,  or  by  waiting  until  some  positive  corroborative 
signs  of  secondaiy  sypliilis  appear.  When  tlie  diagnosis  is  sure  there 
is  no  need  of  further  delay.  In  all  cases  of  doubt  the  honest  surgeon 
must  hesitate,  and  many  cases  arc  doubtful  at  first.  In  all  such  it 
becomes  the  duty  of  the  surgeon  and  of  the  patient  to  wait  for  abso- 
lute proof  of  its  presence  before  treating  a  disease  wliich  possibly  ma}' 
not  exist.  By  following  the  opposite  course  the  surgeon  perhaps  throws 
doubt  and  discontent,  sometimes  even  torture,  into  the  wliole  subse- 
quent life  of  the  patient,  Avho  is  constantly  alarmed  by  every  pimple, 
every  ache,  every  unusual  feeling  he  may  have  through  life,  fearing  it 
may  be  the  Ijeginning  of  the  long-delayed  onslaught  of  his  imaginary 
foe. 

A  few  days  of  mercurial  treatment  in  some  cases  will  disturb  the 
regular  development  of  symptoms,  perhaps  prevent  their  appearance 
altogether  in  a  form  whicli  would  be  readily  recognized,  and,  in  face 
of  such  a  case,  if  the  diagnosis  of  the  nature  of  the  chancre  had  been 
doubtful,  how  much  more  so  would  be  that  of  the  subsequent  syphilis  ! 
llence  the  rule  in  all  cases  of  doubt :  Do  nothing  but  frankly  tell  the 
patient  that  he  must  wait ;  or,  if  he  has  not  the  grace  to  appreciate 
pure  honesty  and  must  have  something  to  do  while  waiting,  give  a 
jjlacebo  while  studying  the  nature  of  the  sore  and  awaiting  develoj)- 
ments.  As  soon,  however,  as  the  diagnosis  "syphilis  "  is  satisfactory, 
commence  general  treatment.  All  through  syphilis  mercury  has  power, 
an  eliminative  and  controlling  power  if  not  a  curative  one.  Curative 
it  is  not  in  the  sense  of  aborting  or  materially  shortening  the  natural 
course  of  the  disease.  The  best  that  can  be  said  of  it  is  that  the 
symj)toms  of  syphilis  are  controlled  by  mercury  better  than  by  any 
other  known  drug,  unless  it  be  the  iodidic  preparations,  and  these 
latter  do  not  posti^oue  relaj)se  or  give  as  good  a  guarantee  against 
severe  late  tertiary  symptoms  as  does  a  prolonged,  thorough  course  of 
mercury.  This  is  simply  the  expression  of  a  personal  opinion,  but  it 
tallies  with  the  present  belief  of  the  majority  of  the  best  authorities 
upon  this  subject  at  the  present  date  in  all  civilized  lands.  Because 
such  distinguished  gentlemen  as  Diday,  Sigmund,  and  Zeissl  have 
expressed  a  belief  that  many  cases  of  syphilis  get  well  as  kindly  with- 
out mercury  as  with  it,  is  nothing  to  the  point.  They  so  state  because 
they  believe  mercury  to  be  an  evil  in  itself  to  be  avoided  when  possi- 
ble. When  they  encounter  a  bad  case  of  syphilis,  they  use  mercury, 
choosing  it  as  it  were  for  the  short  horn  of  a  dilemma.  They  seem  to 
say.  Syphilis,  is  a  bad  thing,  but  if  not  very  bad,  do  not  let  us  add  to 
the  patient's  misfortunes  by  inflicting  upon  him  another  bad  thing — 
i.  e.,  mercury.  Yet,  they  say,  mercury  docs  control  the  symptoms,  else 
why  do  they  employ  it  in  severe  cases  ?  In  such  cases  they  seem  to 
say.  Mercury  is  bad,  but  less  bad  than  severe  syphilis.  Now,  if  it 
can  be  shown  that  mercury  in  itself  is  not  bad  any  more  than  is  a 


SYrniLiZATioN.  557 

knife  ;  if  it  is  bad  only  when  improperly  used  ;  if  it  can  he  used  so  as 
to  be  a  tonic  as  well  as  an  antisyphilitic  remedy — then  the  whole  logic 
of  the  position  of  these  gentlemen  falls  to  the  ground.  For,  if  mer- 
cury is  useful  in  severe  cases,  and  does  control  the  symptoms  of  syphilis, 
and  can  be  so  used  as  not  to  injure  the  patient — then,  in  logic,  to  be 
consistent,  the  drug  should  be  used  for  all  cases,  the  light  as  well  as 
the  severe  ones. 

This  demonstration  of  the  harmlessness  of  mercury,  of  its  tonic  in- 
fluence, I  think  I  have  clearly  made.*  I  have  shown  that  moderate 
doses  of  mercury  continued  for  any  length  of  time  (up  to  several  years, 
a  time  amply  long  so  far  as  syphilis  is  concerned)  not  only  do  not 
debilitate  but  act  as  a  tonic  in  health,  in  disease,  in  syphilis,  augment- 
ing the  number  of  red  cells  in  the  blood.  I  have  amplified  the  sub- 
ject, showing  that  mercury  can  not  be  held  responsible  for  late  lesions, 
in  another  place. f  Finally,  upon  this  foundation,  I  devised  a  method 
of  treatment  which  I  called  the  tonic  treatment  of  syphilis, J  so  nam- 
ing it  because  in  it  mercury  can  be  used  in  such  a  way  as  to  exercise 
its  tonic  influence,  while  at  the  same  time  it  is  controlling  the  disease. 
I  have  been  persistently  misunderstood  in  this  matter.  It  is  not  as  a 
tonic,  or  because  it  is  a  tonic,  that  mercury  cures  syphilis,  or  allevi- 
ates it,  but  mercury  may  be  so  used  in  the  treatment  of  syphilis  that 
over  and  above  its  specific  influence  it  may  still  not  only  do  the  patient 
no  harm,  but  may  be  actually  a  tonic  to  him,  doing  him  good — a  point 
that  no  one  has  hinted  at  before,  and  many  do  not  yet  believe ;  and 
on  this  account  only  I  have  called  this  method  the  tonic  treatment  of 
syphilis. 

Since  my  demonstrations  were  made,  no  one  has  pretended  seriously 
to  controvert  them  except  Hermann  Schlesinger.  This  gentleman,  in 
an  extensive  essay,*  which  received  a  prize  from  the  medical  faculty 
at  Gottingen,  and  represents  an  enormous  amount  of  excellent  work, 
makes  an  experimental  inquiry  into  the  action  of  the  continued  use  of 
small  doses  of  mercury  upon  animals.  He  confirms,  by  numerous  ex- 
periments upon  rabbits  and  dogs,  the  conclusions  which  I  reached, 
but  he  declines  to  agree  with  me  in  calling  the  action  of  the  mercury 
a  tonic  one,  because,  although  the  number  of  the  red  cells  is  increased 
and  held  high,  yet  he  claims  that  this  is  due  to  a  retarding  influence 
on  the  process  of  oxidation,  and  he  thinks  that  only  the  process  of 
destruction  is  retarded,  and  that  the  mercury  leads  to  an  increase  of 
the  deposit  of  fat.  He  states  (after  Petrouski)  that  iron,  when  acting 
as  a  tonic,  increases  the  number  of  red  cells,  the  weight,  the  body  heat, 
the  pulse,  and  the  excretion  of  urea.     Mercury  does  not  act  in  all 

*  "Effect  of  Small  Doses  of  Mercury,"  etc.,  "Am.  Journ.  Med.  Sci.,"  Jan.,  1S76. 
f  "Treatment  of  Syphilis,"  "Trans.  Int.  Med.  Congress,"  1876. 

X  "Tonic  Treatment  of  Syphilis,"  New  York,  ISVyT 

*  "Arch  f.  cxp.  Path  u.  Pharm.,"  Bd.  xiii,  Heft  v,  p.  SIV. 


558  GENERAL   TREATMENT   OF   SVnilLIS. 

these  Tvavs  ;  therefore.  sa3'S  Sclilesingcr,  it  is  not  a  tonic.  But  tliis 
seems  like  siilittiiii;-  liairs.  Syphilis  destroys  red  cells,  mercury  arrests 
the  destructire  process.  Animals  sick  and  wrll,  men  sick  and  well, 
thrive  upon  it  if  given  in  sufficiently  small  doses  for  an  indefinite 
period  ;  no"  harm  comes  to  their  tissues  or  organs.  Therefore,  why  is 
it  not  a  tonic,  even  if  it  does  not  increase  the  heat,  the  pulse,  and  the 
excretion  of  urea  ?  Schlesinger  found  tinit  goats,  sheep,  and  hens  did 
not  do  well  on  mercury  ;  dogs  and  rabbits  did.  Dogs  grew  fat,  and 
although  confined  died  healthy.  One  dog  kept  a  year  showed  a  great 
increase  in  tiie  number  of  his  red  blood-corpuscles.  lie  was  tlien  let 
out  of  his  cage  and  got  sick  (as  might  have  been  expected),  had  diar- 
rhoea, lost  appetite,  and  suffered  a  loss  in  the  number  of  his  red 
cells.  He  recovered,  however,  while  at  large,  still  taking  the  mercury. 
After  his  death  the  only  lesions  found  were  an  atheromatous  patch  in 
the  aorta,  and  some  fatty  degeneration  along  the  urinary  tubules,  the 
vessels  and  glomerules  being  healthy.  It  seems  to  me  that  in  this  case 
there  is  nothing  to  show  that  lack  of  exercise  and  confinement  for  a 
year  did  not  cause  the  atheroma.  It  is  certain  that  the  urine  was  nor- 
mal, for  it  was  examined.  In  man  I  do  not  know  that  mercury  has 
ever  been  accused  of  causing  kidney  disease.  Finally,  tonic  doses  of 
mercury  in  man  do  not  lead  to  inordinate  accumulations  of  fat  obvious 
to  the  eye,  as  was  the  case  in  this  dog,  and  it  may  be  questioned 
whether  he  got  his  projoer  tonic  dose  of  mercury,  and  was  not  overfed 
as  well  as  under-exercised. 

In  the  early  manifestations  of  syphilis  mercury  is  specially  potent. 
Under  its  kindly  influence  the  chancre  heals,  the  early  eruptions  fade. 
If  given  continuously  and  intelligently  from  the  first,  syphilitic  fever 
rarely  amounts  to  more  than  a  little  pallor,  with  occasional  osteocopic 
pain,  and  the  early  eruptions  are  less  generalized  than  they  would 
otherwise  be.  In  many  cases  of  early  syphilis  the  iodides  have  a  more 
prompt  controlling  effect  over  the  lesions  than  the  mercurials.  This 
is  often  the  case  in  ulcerative  throat  and  mouth  troubles,  precocious 
ulcers  and  bone  lesions,  pains,  and  sometimes  in  the  case  of  the  earlier 
eruptions.  Yet  it  is  not  well,  I  believe,  to  use  the  iodides  too  freely 
in  early  syiDhilis.  They  are  not  essential  in  this  stage,  and  by  using 
them  freely  the  patient  gets  accustomed  to  them,  and  when  the  time 
of  urgency  arrives  late  in  the  disease  he  may  not  be  able  -to  digest 
enough  of  the  drug  to  do  what  is  required  of  it.  The  careless  use  of 
the  iodides  early  in  syphilis  is  like  going  to  battle  Avith  one's  whole 
army,  and  not  holding  any  force  in  reserve. 

Along  with  the  tonic  course  of  mercury  hygienic  and  ordinary 
tonic  means  should  be  constantly  employed  in  most  cases.  Mercury 
properly  administered  may  be  taken  for  years  without  any  injury  to 
the  individual,  or  to  his  constitution,  either  immediate  or  remote.  It 
has  no  connection  as  a  cause  with  the  appearance  of  severe  tertiary 


BAD   EFFECTS   OF   MERCURY.  559 

forms  of  syphilis.  Accumulating  experience  derived  from  more  accu- 
rate observation  has  established  this  truth  beyond  cavil,  although  the 
ancient  superstition  as  to  the  injurious  after-effects  of  mercury  still 
measurably  taints  popular  belief.* 

I  have  seen  a  great  many  cases  of  very  severe  tertiary  lesions  upon 
sypliilitic  patients  who  never  had  taken  any  mercury,  and  can  not 
believe  that  this  drug  has  anytliing  to  do  with  suppressing  tljc  disease 
early  and  allowing  it  greater  strength  with  which  to  strike  the  patient 
later.  With  Dr.  Van  Buren  I  have  published  f  two  very  strong  illus- 
trative cases  on  this  point,  and  I  could  add  very  many  more.  I  have 
dealt  with  this  subject  also  in  another  place.  J  Engelstcd,*  of  Copen- 
hagen, states  that  out  of  7,434  cases  of  constitutional  syphilis  treated 
in  hospital  between  1864  and  1876,  493  cases  of  very  severe  destructive 
lesions  occurred  in  patients  who  had  never  taken  any  mercurial  treat- 
ment at  all.  How  many  more  would  have  had  serious  lesions  had 
their  malady  not  been  moderated  by  a  previous  mercurial  course  can 
only  be  conjectured. 

Bad  Effects  of  Mercury. — Occasionally  a  patient  appears  who 
tolerates  mercury  badly.  He  may  be  unable  to  take  a  certain  form — 
the  protiodide,  perhaps,  because  it  causes  pain  and  diarrhoea — but  can 
take  another.  Most  people  tolerate  the  bichloride  kindly,  but  I  have 
seen  a  few  patients  who  could  not  take  any  form  of  mercury  in  an}'- 
thing  approaching  an  efficient  dose  without  suffering  therefrom  great 
loss  of  vitality,  and  being  thrown  into  a  condition  of  apparently  hope- 
less mental  and  moral  depression.  This  curious  condition  is  not  the 
same  as  the  mental  and  emotional  depression  caused  by  the  onset  of 
early  syphilis,  and  it  must  be  carefully  differentiated  from  it.  The 
latter  exists  and  is  common ;  this  mercurial  depression  is  rare,  but  it 
certainly  occurs.  Words  can  hardly  describe  the  awful  gloom  that 
settles  down  on  an  individual  upon  whom  mercury  exercises  this  pe- 
culiar power.  One  form  of  the  remedy  produces  it  as  well  as  another  ; 
striking  relief  is  afforded,  obviously,  by  discontinuing  the  drug,  or, 
what  will  often  answer,  lessening  the  dose.  These  symptoms  may  be 
observed  before  mercury  has  produced  any  effect  upon  the  mouth  or 
gums.     When  a  patient  positively  can  not  take  mercury  at  all,  then 

*  The  sweeping  assumptions  and  broad  assertions  of  a  recent  author  of  a  pretentious 
volume  in  folio  ("  Ueber  die  Wirkungen  des  Quecksilbers  auf  den  meuschliehen  Organis- 
mus,"  Dr.  Jos.  Hermann),  which  would  seem  to  ascribe  all  possible  evils,  and  especially 
the  symptoms  of  syphilis,  to  the  effects  of  mercury,  are  too  little  substantiated  by  the 
facts  adduced  to  call  for  any  discussion  here.  An  extensive  mercurial  bibliography  (but 
nothing  else  of  value,  not  even  a  good  suggestion)  can  be  found  in  "  Die  Anti-Mercurialis- 
mus  in  der  Syphilis-Therapie,"  J.  K.  Prokseh,  Erlangen,  1874. 

f  "Archives  of  Dermatology,"  1.  ii,  p.  lOS. 

X  "  Treatment  of  Syphilis,"  "  Trans.  Int.  Med.  Cong.,"  Phila.,  ISVG. 

*  "Klinisk  Veilcdning  til  Diagnose,  Behandlung,"  etc.,  1877,  and  "Am.  Journ.  Med, 
Sci.,"  January,  1878,  p.  231. 


560  GENERAL  TREATMENT  OF  SYPHILIS. 

we  have  to  fall  back  upon  the  iodides  (which  also  sometimes  fail  us), 
gold,  the  vegetable  remedies,  or  somethiug  else — touics,  mineral  waters, 
and  the  like. 

The  other  bad  effects  produced  by  mercury  arc  salivation  and  diar- 
rhoea, with  griping  pain.  The  well-known  poisonous  effects  of  the 
stronger  mercurials  (bichloride,  biniodidc,  bicyanidc,  etc.)  render  it 
unnecessary  to  discuss  death  from  an  overdose  of  one  of  the  latter  class. 
The  general  intelligence  of  modern  practitioners  renders  it  equally 
unnecessary  to  more  than  allude  by  name  to  mercurial  tremor  and  mer- 
curial cachexia,  neither  of  which  could  occur  except  after  an  inordinate, 
unjustifiable  use  of  the  drug,  although  mild  tremors  arc  noticed  some- 
times after  mercurial  baths.  (For  the  irritating  effects  of  mercury  used 
locally,  see  Inunction.) 

Salivation. — Salivation  is  harmful.  It  should  not  be  aimed  at. 
The  greatest  effect  that  it  is  allowable  to  produce  by  mercury  is  to 
**  touch  the  gums,"  as  it  is  called.  When  the  gums  are  touched  there 
will  be  an  increased  flow  of  saliva,  a  faint  coppery  taste  in  the  mouth, 
some  tenderness  of  the  gums,  tongue,  perhaps  of  the  whole  buccal 
cavity.  Pressing  the  teeth  firmly  together  causes  slight  jiain,  while  a 
little  swelling  of  the  gums  and  a  faint  reddish  line  at  the  neck  of  the 
teeth  may  be  noticeable.  Sometimes  ulceration  along  the  edges  of  the 
tongue  or  gums,  or  on  the  inside  of  the  cheek,  is  caused  by  mercury, 
while  there  is  still  no  tenderness  about  tlie  mouth,  nor  a  very  markedly 
increased  flow  of  saliva ;  but  this  is  rare. 

The  mouth  should  be  inspected  before  commencing  a  mercurial 
course,  so  that  the  condition  of  the  teeth  and  gums  may  be  known. 
A  patient  with  ragged  teeth  covered  with  tartar  is  not  in  a  fair  condi- 
tion to  test  the  therapeutic  effect  of  mercury ;  his  gums,  naturally 
tender,  will  become  affected  long  before  his  point  of  true  tolerance  is 
reached.  It  is,  therefore,  wise  in  commencing  a  mercurial  course,  to 
send  the  patient  to  a  dentist,  with  injunctions  to  have  the  tartar  en- 
tirely removed  from  his  teeth,  both  to  make  the  observation  of  the 
effect  of  mercury  more  accurate,  and  to  remove  one  source  of  local 
irritation  capable  of  keeping  up  mucous  patches.  The  quantity  of 
the  drug  necessary  to  produce  an  effect  upon  the  gums  varies  with 
each  individual ;  minute  doses  will  occasion  it  in  some  cases  having 
special  idiosyncrasies ;  others  may  take  enormous  doses  before  the 
symptoms  yield  or  the  gums  become  affected.  The  point  of  satura- 
tion or  "tolerance"  of  a  given  patient  can  only  be  learned  by  close 
observation  of  the  symptoms  just  described.  After  this  we  have  his 
gauge,  and  can  temper  his  treatment  according  to  the  urgency  of  his 
symptoms.  Should  salivation  accidentally  occur,  or  be  encountered 
in  practice,  it  requires  treatment.  The  effect  of  mercury  is  by  no 
means  increased  by  keeping  a  patient  salivated  ;  on  the  contrary,  the 
disease  is  not  benefited,  while  the  patient  is  positively  injured. 


BAD   EFFECTS   OF   MERCURY.  5gl 

The  cause  of  salivation  is  special  idiosyncrasy  with  a  small  dose  of 
mercury,  or  no  idiosyncrasy  with  large  doses.  A  mouth  kept  dirty  or 
containing  bad  teeth  is  more  apt  to  suffer.  The  influence  of  cold  and 
wet  during  a  mercurial  course  seems  sometimes  (though  very  rarely) 
capable  of  inducing  it.  Bumstead  mentions  a  patient  who  became 
"profusely  salivated  a  month  after  the  cessation  of  a  mercurial  course 
as  a  consequence  of  exposure  to  the  rain." 

Symptoms. — In  salivation  the  salivary  fluids  flow  freely,  sometimes 
to  an  enormous  extent ;  the  breath  is  fetid,  the  metallic  taste  is  very 
marked  ;  the  gums  are  sore,  perhaps  bleeding  ;  the  teeth  feel  too  long 
for  the  patient  to  shut  his  mouth — tapping  lightly  upon  them  causes 
pain  ;  the  tongue  swells,  showing  marks  of  the  teeth  ;  the  lips  and 
cheeks  may  also  become  tumefied.  Often  there  is  febrile  excitement 
with  mental  depression  ;  the  lymphatic  glands  in  the  vicinity  become 
swollen  and  painful.  The  teeth  may  fall,  or  portions  of  the  soft  or 
bony  parts  necrose,  in  extreme  cases.  Articulation  is  indistinct  and 
painful,  deglutition  almost  impossible. 

The  above  is  a  description  of  a  severe  type  case  of  mercurial  stoma- 
titis. Between  this  and  the  mildest  increase  in  the  salivary  flow  with 
"touching  of  the  gums,"  the  affection  assumes  all  shades  and  varie- 
ties of  intensity.  The  patient  should  be  cautioned  to  report  for  in- 
spection on  the  advent  of  the  earliest  of  these  symptoms,  that  possibly 
impending  salivation  may  be  averted. 

Treatment. — Salivation  may  often  be  kept  off  by  the  administra- 
tion of  large  doses  of  the  chlorate  of  potash  during  a  mercurial  course, 
and  that,  too,  without  interfering  with  the  effects  of  the  mercury,  as 
Ricord  has  shown,  but  it  is  better  to  hold  this  remedy  in  reserve  for 
exhibition  in  case  symptoms  of  mercurial)  zation  should  suddenly  run 
high.  During  salivation,  or  any  sore  mouth  from  mercury,  ten  to 
twelve  grains  to  the  ounce  of  chlorate  of  potash  in  water,  or  any  bland, 
fluid,  should  be  kept  constantly  on  hand  (warmed),  and  with  it  the 
patient  should  repeatedly  rinse  his  mouth  and  throat.  At  least  one 
drachm,  and  not  more  than  two,  of  the  same  remedy  daily  should  be 
introduced  into  the  patient's  circulation,  either  through  the  stomach, 
if  he  can  swallow,  or  by  the  rectum.  A  mild  solution  of  carbolic  acid 
or  of  Labarraque's  solution,  or  water  rendered  pink  with  a  little  per- 
manganate of  potash,  should  be  occasionally  used  as  a  gargle,  where 
there  is  great  fetor  of  the  breath.  The  free  use  of  the  hot  bath  is  of 
advantage  in  cases  of  salivation,  and  of  a  bland,  mild  diuretic,  prefer- 
ably a  diluent  water  such  as  Poland  or  Bethesda.  The  diarrhoea, 
unless  very  profuse,  should  not  be  stopped,  for  the  escape  of  the  mer- 
cury takes  place  most  freely  from  the  intestine,  next  by  the  kidneys 
and  skin,  and  these  channels  should  be  kept  open  and  their  activity 
encouraged.  A  little  tincture  of  belladonna  may  be  given  to  restrain 
the  salivary  flow  and  comfort  the  patient,  or  atropia  may  be  used 

86 


562  GENERAL  TKEATMEXT  OF  SYPHILIS. 

hypodcrmically,  y  J  o"  of  a  grain  at  a  dose,  repeated  every  six  hours  until 
the  pupils  show  the  elfect.  Astringent  gargles,  Labarraijue's  solution, 
tincture  of  myrrh,  hot  milk,  cold  tea,  and  other  substances  (gum-water) 
may  be  used  as  mouth-washes  tentatively.  These  means  will  gener- 
ally promptly  overcome  salivation.  In  all  other  respects  the  treat- 
ment of  salivation  is  symptomatic.  An  anodyne  or  a  laxative  may  be 
required — the  physician  selects  the  one  with  the  use  of  which  he  is 
most  familiar.  Nourishment  must  be  kept  up  by  hot  broths,  milk, 
and  soft  articles  of  light  food,  until  a  subsidence  of  the  swelling  allows 
the  patient  to  swallow  solids. 

Diarrhoea  with  griping  pains  is  apt  to  come  on  in  many  patients 
who  arc  fairly  under  the  inlluence  of  mercury.  If  kept  up,  the  patient 
loses  appetite,  runs  down,  and  fails  to  derive  benefit  from  his  mercu- 
rial course.  When  any  mercurial  shows  signs  of  disagreeing  by  the 
production  of  these  symptoms,  it  is  better  to  lower  the  dose,  if  the 
syphilitic  lesions  are  under  control ;  otherwise,  to  change  the  mercurial 
preparation  for  a  milder  one,  putting  the  patient  at  the  same  time 
upon  a  rice-and-milk  diet,  with  linie-Avater  and  moderate  doses  of  bis- 
muth, or  to  administer  the  mercury  by  some  other  method — inunction, 
fumigation.  Opiates  and  astringents  may  be  combined  with  the  mer- 
curial, to  prevent  its  irritating  effects,  but  it  is  better  to  avoid  them 
if  possible,  or  in  any  case  to  try  first  the  means  above  suggested. 

Elimination  of  Mercury  from  the  Body. — Mercury  gets  out  of  the 
body  chiefly  through  the  intestinal  canal,  then  through  the  salivary 
glands,  the  kidneys,  the  skin.  Schuster,*  of  Aix-la-Chapelle,  has  made 
a  study  of  the  elimination  of  the  drug  to  determine  how  long  it  re- 
mains in  the  system  after  the  patient  has  ceased  taking  it  by  inunc- 
tion. His  methods  (the  Ludwig-Fiirbringer  modified  by  Schridde) 
seem  to  have  been  very  thorough.  Sometimes  mercury  is  found  in 
the  urine  during  and  after  a  mercurial  course,  sometimes  it  is  absent. 
Its  quantity  in  the  urine  is  not  great.  In  the  contents  of  the  rectum 
it  is  always  present  in  large  quantities.  Forty  examinations  of  fseces 
found  mercury  in  relatively  large  quantity  during  the  inunction  course. 
It  continued  for  five  and  a  half  months  after  the  end  of  the  course, 
never  later.  From  this,  Schuster  concludes  that  mercury  is  not  stored 
in  the  organism,  but  is  eliminated  at  a  uniform  rate  during  six  months, 
after  a  long  (forty-five  days)  inunction  course.  He  thinks  that  traces 
might  be  found  at  eight  months,  but  not  later.  Many  patients,  ex- 
amined eight  and  twelve  months  after  treatment,  did  not  show  a  trace 
of  mercury  under  analysis.  Vajda  and  Faschkis,t  reflecting  the  doc- 
trines of  the  Sigmund  school,  tried  to  prove  that  mercury  is  irregu- 
larly eliminated  from  the  organism  through  the  kidneys.  They  claim 
to  have  found  mercury  in  the  urine,  two,  three,  five,  seven,  and  thir- 

*  "Journ.  of  Cut.  and  Venereal  Diseases,"  September,  1883,  p.  353. 
\  "Ueber  den  Einfluss  des  Hydrargyrum,"  etc.,  Wien,  1880. 


METHODS  OF  ADMINISTERING   MERCURY.  5G3 

teen  years  after  the  cessation  of  relatively  short  courses  of  inunction. 
Schuster  objects  to  these  conclusions  because  the  patients  furnisiiing 
the  urine  in  the  last-mentioned  set  of  cases  had  remained  a  certain 
time  in  Sigmund's  wards — several  of  them  as  long  as  thirteen  days — 
before  the  urine  was  tested.  Schuster  believes  that  in  this  time  they 
inhaled  enough  mercury  from  the  patients  being  treated  by  inunc- 
tion to  show  traces  in  the  urine.  Vajda's  experiments,  showing 
absence  of  mercury  from  the  air  of  the  wards,  are  balanced  by  Lese- 
mann's  *  report  of  one  hundred  and  forty-four  cases  in  the  Kalinkin 
Hospital,  St.  Petersburg,  who  states  that,  notwithstanding  the  small 
amounts  of  mercurial  ointment  used  (3j  to  3  j),  stomatitis  occurred 
not  only  in  patients  under  treatment,  but  in  those  using  no  mercury. 
Pie  ascribes  this  to  mercurial  vapors  in  the  ward,  but  it  seems  like 
begging  the  question  when  one  man  finds  what  no  one  else  has  ever 
observed.  Consequently  my  impression  is  that  the  last  word  has  not 
been  spoken,  and  the  evidence  is  not  all  in,  the  reports  thus  far  com- 
ing from  prejudiced  persons,  those  having  a  point  to  make.  Such 
observers  can  never  view  a  subject  in  a  judicial  way.  Yet  Schuster's 
investigations  are  valuable  and  must  stand  for  the  present — ^until  con- 
troverted. 

Methods  of  administering  Mercury. — The  effects  of  mercury  are 
produced  no  matter  how  the  drug  is  employed  ;  hence  the  choice  of  a 
method  depends  mainly  upon  the  ease  of  its  administration,  the 
promptitude  of  its  action,  or  upon  the  desire  to  i^roduce  or  to  avoid 
some  local,  useful,  or  disagreeable  effects.  It  is  on  this  account  that, 
for  treating  general  syphilis,  the  method  by  the  stomach  is  the  best. 
Since  it  is  necessary  to  continue  the  use  of  mercury  for  a  long  time, 
unremittingly  and  continuously,  it  becomes  at  once  apparent  that  the 
docility  of  the  patient  is  taxed  severely  to  keep  him  under  treatment 
at  all,  and  common  sense  avers  that  the  ordinary  patient  will  take  his 
medicine  steadily  by  the  mouth  in  many  cases  where  he  would  abso- 
lutely refuse  to  continue  it  by  any  other  method — as  by  the  hypoder- 
mic injection,  inunction,  fumigation.  All  of  these  methods  have  their 
value  in  the  rapidity  of  their  action,  and  from  the  fact  that  they  spare 
the  stomach  ;  but,  for  prolonged,  regular  treatment,  the  latter  organ 
must  be  relied  upon.  Even  the  advocates  of  other  methods  do  not 
propose  them  for  continuous  use,  but  only  to  combat  symptoms — call- 
ing the  disappearance  of  an  eruption  a  cure  of  sj^philis,  and  the  next 
eruption  a  relapse. 

Among  the  methods  in  common  use  for  the  administration  of  mer- 
cury at  the  present  date,  five  require  mention.  They  are,  in  the  order 
of  their  I'espective  value  to  the  practitioner  : 

1.  By  the  stomach. 

2.  Local. 

*  "St.  Petersb.  med.  Wchnschr.,"  March  13,  1883. 


56-4  GENERAL   TREATMENT   OF   SYrniLIS. 

3.  Endcrmic  (inunction). 

4.  Fumigation. 

5.  Hypodermic. 

5.  Hypodermic  Injections. — In  favor  of  this  method,  first  used  by 
Scarenzio,  of  Pavia,  in  1854,  it  may  be  said  that  eru])tions,  iritis,  and 
lesions  relievablo  by  mercury,  seem  to  yield  very  rapidly  during  its 
employment,  as  a  rule.  The  method  employed  is  tlwt  of  Lewin,* 
more  or  less  modified.  From  one  sixteenth  to  one  eiglith  of  a  grain  of 
sublimate,  with  perhaps  a  little  morj)hine,  dissolved  in  fifteen  minims 
of  water,  is  injected  once  or  twice  daily  under  the  skin — preferably 
of  the  back  below  the  scapula,  or  deeply  in  the  gluteal  region.  Any 
number  of  other  mercurial  preparations  have  been  used  and  had  ardent 
advocates.  Calomel  is  bad,  because  it  very  often  causes  abscess  ;  the 
urate  of  mercury  is  said  to  be  very  bland — I  have  not  tried  it ;  various 
albuminates  and  mercuric  peptones  have  given  good  results,  but  their 
preparation  is  troublesome  and  they  do  not  keep.  The  same  objection 
(that  of  instability)  holds  against  that  admirable  preparation  devised 
by  Licbreich,  the  formamida  of  mercury.  It  is  difficult  to  procure  in 
this  country,  and  will  not  keep.  I  have  used  it  subcutaneously  with 
admirable  effect  in  some  severe  cases  where  I  wished  to  spare  the 
stomach.  It  does  all  that  can  be  expected  of  a  mercurial,  and  is  less 
irritating  in  its  local  effect  than  simple  corrosive  sublimate.  But  the 
latter  answers  perfectly  well.  It  is  always  at  hand  and  easy  to  pre- 
pare, and,  if  freshly  made  in  distilled  water  and  deeply  injected,  it  never 
(in  my  hands  at  least)  produces  local  abscess,  although  it  often  causes 
moderate  pain.  It  is  prompt  in  its  action,  and  a  dail}^  dose  of  one 
sixteenth  of  a  grain  is  usually  enough,  but  may  be  doubled.  The  objec- 
tions to  the  hypodermic  treatment  are,  however,  sufficient  to  condemn 
it  unless  in  exceptional  cases,  where  the  patient  can  not  take  the  drug 
by  the  stomach  for  any  reason,  or  when  a  very  speedy  and  pronounced 
action  is  required  for  a  short  time.  Abscess  may  follow  the  puncture, 
or  a  hard,  painful  lump,  lasting  some  time.  Salivation  may  be  pro- 
duced unless  considerable  Avatchfnlness  is  observed.  The  injection  of 
calomel,  or  yellow  oxide  of  mercury,  in  vaseline-oil,  now  popular  in 
Paris,  is  not,  in  my  opinion,  to  be  commended.  Its  effect,  often  brill- 
iant, sometimes  fails,  while  the  pain  experienced  occasionally  disables 
the  patient  for  days.  I  do  not  think  that  the  method  can  ever  be- 
come popular  in  private  practice.  I  have  tested  it  only  among  dis- 
pensary patients,  and  have  abandoned  it. 

4.  Fumigation. — This  method  is  an  excellent  one,  but  not  practi- 
cably applicable.  It  requires  an  expenditure  of  time  and  care,  such  as 
the  ordinary  patient  will  not  continue  to  give  it*for  a  long  time.  It  is 
useful  where  prompt  and  kindly  action  of  mercury  is  aimed  at.  Im- 
provement of  symptoms  sets  in  rapidly  after  the  baths  are  commenced. 

*  "  Beliandlung  der  Syphilis  mit  subcutaner  Sublimat-Injection." 


FUMIGATION. 


505 


Salivation  is  rarely  induced.  Fumigations  may  be  taken  daily,  where 
the  patient  is  robust  and  bears  the  treatment  well,  for  three  or  four 
days,  but  then  the  interval  must  be  lengthened,  and  once  a  week  is 
usually  enough  to  keep  up  the  mercurial  effect.  Depression,  headache, 
faintness,  tremors,  occasionally  salivation,  or  diarrhoea,  attend  this 
mode  of  treatment,  when  the  patients  are  impressionable.  Langston 
Parker*  has  done  much  to  develop  this  form  of  treatment. f 

The  best  method  of  fumigation  is  that  found  in  Turkish  bathing 
establishments.  The  simplest  method  for  domestic  use  is  the  follow- 
ing :  Direct  the  patient  to  procure  at  a  tin-store  a  piece  of  tin  ten 
inches  long  by  three  and  one  half  broad.  This  should  be  bent  to  a 
right  angle  at  two  and  one  half  inches  from  either  end,  or  at  a  con- 
venient distance  for  the  action  of  a  flame  from  a  low  (tin)  spirit-lamp 
placed  beneath  the  table,  formed  by  bending  the  ends  of  the  tin 
(Fig.  112). 

Upon  this  ''table  "  the  powder  to  be  volatilized  is  scattered.  The 
patient  undresses  entirely.  The  lamp  and  tin,  covered  with  the  mer- 
curial selected,  are 
placed  in  position 
beneath  a  cane-bot- 
tomed chair.  The 
patient,  naked,  sits 
upon  the  chair,  and 
wraps  himself  and 
the  chair  completely 
in  a  couple  of  thick 
blankets,  drawing 
the  latter  snugly  be- 
neath  his   chin.     A 

Bunsen  burner  attached  to  the  gas-fixture  by  a  rubber  tube  will  give 
a  better  volatilization  than  a  spirit-lamp — but  the  latter  answers  very 
well.  A  pan  of  steaming,  boiling  water  is  now  placed  under  the 
blankets.  As  soon  as  the  confined  steam  has  rendered  the  body  warm 
and  slightly  moist,  the  spirit-lamp  under  the  chair  is  ignited.  The 
bath  lasts  from  fifteen  minutes  to  half  an  hour.  Profuse  perspiration 
usually  comes  on.  After  fifteen  minutes,  if  the  patient  is  uncomfort- 
able, the  light  may  be  extinguished,  but  remaining  in  the  fumes  five 
or  ten  minutes  longer  is  of  advantage.     The  patient  now  wraps  one 

*  "  On  Syphilitic  Diseases,"  London. 

f  Mercurial  fumigations  are  administered  in  most  of  the  Turkish  and  Russian  battling 
establishments  in  all  large  cities ;  but  it  is  the  universal  experience  of  physicians  that 
the  proprietors  of  these  establishments  are  prone  to  tamper  with  patients,  and  invariably 
fail  to  carry  out  instructions  received  from  the  physician.  Otherwise  the  facilities  of 
such  establishments  of  mingling  steam  with  the  fumes  of  mercury  are  unequaled.  In 
these  institutions,  where  the  head  is  also  immersed  in  the  fumes,  the  black  oxide  is  the 
most  suitable  mercurial  to  be  employed — from  one  to  two  drachm  doses. 


Fig.  113. 


566  GENERAL  TREATMENT  OF  SYPHILIS. 

of  the  blankets  aroiiud  him  aud  lies  down,  without  wiping  off  the 
mercury,  until  he  has  cooled. 

Of  the  different  mercurials  generally  used  in  fumigation,  calomel  is 
the  best.  About  a  !^cruple  is  enough  for  a  batli  ;  the  diminution  or 
increase  of  this  dose  is  regulated  by  circumstances.  Calomel  is  better 
than  the  other  substances  used,  because  it  volatilizes  promptly  with  a 
heat  easily  attained  by  a  spirit-lamp,  and  whatever  of  the  fumes  escapes 
into  the  room  is  not  irritating  to  the  fauces.  The  red  oxide  of  mercury 
also  volatilizes  without  reduction.  All  the  other  substances  in  common 
use — metallic  mercury,  mercury  with  chalk,  the  gray  oxide,  the  black 
oxide,  the  binoxide,  the  yellow  oxide,  the  bisulphuret — are  exactly  the 
same  thing  ;  they  all  reduce  lirst,  and  tiien  the  metallic  mercury  vola- 
tilizes. Pure  metallic  mercury  boils  at  GG2°,  and  is  apt  to  sputter  on 
the  application  of  dry  heat  before  it  volatilizes.  It  takes  considerable 
heat  to  vai)orize  it.  AVhen  the  red  sulphuret  of  mercury  is  employed, 
the  fumes  are  tiiose  of  sulphurous  acid  and  metallic  mercury ;  the 
former  is  often  irritating  to  the  pharynx  and  lungs,  and  the  prepara- 
tion should  not  be  used  without  circumspection.  Calomel  is  often 
objectionable  if  the  head  is  kept  in,  as  the  inhalation  of  its  vapor  in 
some  instances  gives  rise  to  intense  paroxysms  of  coughing,  often  pro- 
longed, spasmodic,  and  painful ;  others  inhale  the  calomel  vapor  with- 
out distress.  The  black  oxide,  3  j  or  3  ij,  can  be  used  if  a  Bunsen  burner 
is  employed.     Its  fumes  are  very  bland. 

3.  Immctmi.— This  is  perhaps,  of  all,  tlie  best  means  of  exhibiting 
mercury.  It  spares  the  stomach,  and  is  thorough  and  efficient ;  saliva- 
tion produced  by  it  is  usually  announced  by  coming  on  slowly,  and  need 
not  generally  be  allowed  to  become  severe.  It  may  produce  any  of  the 
bad  effects  of  mercury,  but  is  not  likely  to  do  so  if  watched.  But  it  can 
not  be  used  for  continuous  or  for  very  mild  treatment.  The  dose  can 
not  be  strictly  regulated,  because  it  is  impossible  to  know  how  much 
is  absorbed  ;  its  application  is  very  dirty,  and  it  sometimes  produces  a 
local  eruption  (mercurial  eczema)  which  is  annoying. 

I  have  tried  preparations  made  with  lanolin,  but  dislike  them. 

The  oleates,  which  I  formerly  used,  I  have  given  up.  They,  too, 
irritate  the  skin— not  always,  but  oftener  than  ordinary  mercurial 
ointment. 

I  believe  that  there  are  only  two  methods  of  using  mercurial  in- 
unction that  are  generally  satisfactory.  One,  not  the  best  one,  but 
suitable  for  some  cases,  and  especially  for  infants  upon  whom  it  is  de- 
sired to  try  the  inunction  method,  is  the  method  known  as  Tcale's. 
Some  mercurial  ointment  is  spread  upon  a  ])atch  as  large  as  the  palm 
of  the  hand  or  thereabouts,  and  this  is  bound  about  the  arm,  forearm, 
leg,  thigh,  body,  as  the  case  may  be,  the  ointment  being  kept  upon 
the  thin  skin,  changed  from  time  to  time,  and  shifted  when  the  under- 
lying skin  begins  to  show  signs  of  redness,  or  to  itch.     Such  a  band- 


INUNCTION— LOCAL   USE   OF   MERCUKY.  507 

age,  or  two  of  them  at  a  time,  may  be  worn  night  and  day,  sometimes 
for  weeks,  without  being  shifted.  In  other  cases  they  have  to  be 
changed  every  few  days,  because  the  skin  begins  to  show  signs  of 
irritation.  When  the  bandage  is  removed,  the  surface  sliould  be 
thoroughly  washed  with  warm  soap  and  water  and  left  dry. 

Decidedly  the  best  method  of  inunction,  in  my  opinion,  is  that 
practiced  at  the  hot  springs.  When  I  use  inunction  upon  the  adult 
I  generally  employ  this  method.  The  patient  takes  a  bath,  a  long 
one,  in  hot  water.  After  drying  himself  he  sits  astraddle  a  chair, 
with  his  face  toward  the  back  of  the  chair,  his  arms  folded  upon  the 
back,  and  his  chin  resting  upon  his  arms.  An  attendant  now  rubs  in 
broadly,  and  with  a  vigorous  circular  motion  of  the  hand,  over  the 
entire  back  a  given  quantity  of  mercurial  ointment,  generally  one 
eighth  or  one  sixth  of  an  ounce  at  a  rub.  The  friction  continues  for 
twenty  minutes.  If  the  frictioner  fears  mercurialization,  he  may  pro- 
tect his  hand  with  a  rubber  glove.  The  ointment  thus  rubbed  in  is 
left  upon  the  back,  and  the  patient  puts  on  first  a  thin  gauze  under- 
shirt (which  he  wears  a  week  as  a  mercurial  shirt),  and  over  this  his 
ordinary  undershirt  and  customary  clothing.  At  the  end  of  twenty 
to  twenty-two  hours  the  patient  takes  another  hot  soap-and-water 
bath,  is  thoroughly  washed  and  dried,  and  takes  another  friction,  as 
on  the  previous  day,  again  putting  on  his  mercurial  shirt. 

Such  a  course  in  New  York  generally  produces  mild  commencing 
salivation  in  a  week,  if  it  is  thoroughly  done. 

Inunction  is  most  valuable  in  severe  chronic  lesions  of  the  brain 
and  spinal  cord,  and  when  a  prompt,  thorough  mercurialization  is 
desired  for  any  reason. 

2.  Local  Use  of  Mercury. — The  local  treatment  of  the  various  syphi- 
litic lesions  is,  of  course,  subordinate  to  the  general  treatment,  but 
yet  it  is  often  of  considerable  importance,  and  spares  the  patient  the 
necessity  of  considerable  internal  dosing.  An  outline  of  many  general 
applications  for  local  use  will  be  given  here  to  avoid  repetition.  If 
any  special  local  means  is  particularly  ap})licable  to  any  individual 
lesion,  it  will  be  alluded  to  again  when  considering  that  lesion. 

Local  Measures  stcitable  to  Cutaneous  Lesions. — The  early  erwp- 
tions  require  no  local  treatment,  except  for  such  of  the  lesions  as  ap- 
pear upon  the  hands  and  face  and  cause  an  unsightly  appearance. 
The  best  local  applications  for  these  lesions  are  the  mercurial  ones. 
Tertiary  groups  of  dry  lesions  also  sometimes  improve  faster  under 
local  mercurial  applications,  or  if  a  mercurial  solution  is  injected  into 
the  subcutaneous  tissue  beneath  them.  Ulcerative  forms  do  better 
under  iodoform,  or  sometimes  stimulating  applications  (chloral). 

The  mercurial  local  applications  to  do  good  locally  must  stimulate 
as  much  as  possible,  and  irritate  as  little  as  possible.  Hence  there  must 
be  a  graded  strength  in  all  local  applications,  and,  if  their  use  causes 


568  GENERAL  TREATMENT  OF  SYPHILIS. 

the  skiu  iuA'olvod  iu  the  lesions  to  grow  red,  ghissy,  or  to  excoriate, 
they  are  too  strong,  and  must  be  discontinued. 
I  use  mostly  the  following  formuliy  : 

9     Ilvdrarg.  oleat.,  5  to  10  per  cent. 

5     Ilydrarg.  chloiid.  corros.,  gr.  j-iv. 

Spts.  rcct.,  q.  s. 

Glycerin,  V[  xx. 

Aquffi,  ad  3  j. 

R     Hydiarg.  ammoniat.,  3  j-  3  jss. 

Ungt.  atiiuc  rostr,  §  j. 

R     Ilyilrarg.  chlorid.  niitis,  3  j-ij- 

Adipis,  .    3  j. 

R     Ilydiarg.  oxid.  flav.  3  ss-  3  jss. 

Ungt.  aquae  rosse,  3  j. 

R     Ilvdrarg.  acid  nitrat.,  used  pyre  with  a  glass  rod,  or  diluted  and 
applied  only  to  small  areas  at  a  time. 

R     Hydra rg.  oxid.  rub.,  gr.  xx-  3  ij. 

Ungt.  aqutC  rosae,  3  j. 

R     Hydrarg.  iodid.  virid.,  gr.  xv-  3  j. 

Ungt.  aqua?  rosse,  3  j. 

R     Ungt.  hydrarg.  nitratis,  diluted  at  first. 

Preparations  of  tar  and  oxide  of  zinc  are  often  also  in  place. 

Mucous  imtches  upon  the  skin  do  well  if  kept  dry  and  painted  with 
the  bichloride  solution,  or  touched  with  the  acid  nitrate  of  mercury, 
diluted  three  to  five  times.  Mucous  patches  at  the  anus,  alongside 
the  scrotum,  under  the  foreskin,  between  the  toes,  under  the  breasts, 
or  between  any  two  overlying  portions  of  skin  which  keep  the  surfaces 
moist  and  sodden,  and  favor  putrescence,  require  cleanliness,  disinfec- 
tion with  Labarraque's  solution,  permanganate  of  potash,  or  corrosive 
chloride  of  mercury,  in  mild  solution,  to  be  kept  as  dry  as  i^ossible  by 
the  interposition  of  absorbent  cotton,  and  dusted  with  calomel,  pure 
or  combined  with  bismuth,  oxide  of  zinc,  or  iodoform.  The  nitrate- 
of-silver  pencil  is  of  service  in  these  cases. 

Ulcerated  Lesions  upon  the  Shin. — The  local  treatment  of  these  is 
often  simply  protective  and  disinfectant ;  cleanliness,  balsam  of  Peru, 
the  use  of  the  black  and  reduced  yellow  washes,  iodoform  powder,  or 
simple  mutton  tallow,  to  prevent  the  edges  of  the  ulcer  from  sticking 
to  the  dressings.  This  is  when  the  ulcers  are  fresh,  and  being  actively 
treated  by  internal  means.  "When  they  grow  old  with  hard  edges,  an 
uneven  base  without  granulations,  then  they  call  for  l(5cal  stimulating 
measures,  scraping,  scarification  of  the  edges,  hot  local  fomentations, 
the  prolonged  hot  bath.  Chloral,  gr.  v-xx  in  the  ounce  of  water,  is 
a  useful  local  application  to  make  granulations  sprout.     Strapping 


USE   OF   MEKCUKY   I5Y   THE   STOMACH.  5fj9 

with  adhesive  strips,  pressure  by  rubber  blindage,  all  local  measures  of 
a  surgical  sort  applicable  to  chronic  ulcers,  come  into  play  lierc.  If 
dead  bono  lies  at  the  bottom  of  an  ulcer,  it  must  separate  before  tlio 
ulcer  will  get  well.  Sinuses  must  be  opened  and  scraped,  and  full 
attention  given  to  hygienic  and  general  dietetic  measures  in  the  treat- 
ment of  the  more  obstinate  of  these  cases. 

Local  Treatment  of  Lesions  upon  Mucous  Membranes. — Cleanli- 
ness is  the  first  requisite  in  the  management  of  all  syphilitic  lesions 
upon  mucous  membranes,  and  the  removal  of  all  irritating  agents. 
The  teeth  should  be  cleaned  with  a  soft  brush,  all  tartar  removed, 
jagged  edges  of  teeth  filed  down,  and  old  stumps  extracted.  Tobacco 
should  be  stopped  where  there  are  mouth  lesions,  for  its  use  either  in 
chewing  or  smoking  will  often  more  than  counterbalance  the  effect  of 
local  and  general  treatment.  The  sexual  parts  and  anus,  if  involved, 
must  be  kept  as  far  as  possible  clean  and  dry.  Gargles  and  soothing 
mouth-washes,  borax,  alum,  chlorate  of  potash,  flaxseed  infusions, 
myrrh,  tannin,  and  other  substances  may  be  used  with  advantage  in  a 
general  way  when  the  mouth  is  the  seat  of  syphilitic  lesions.  A  mouth- 
wash made  with  one  grain  of  Keith's  muriate  of  hydrastin  to  the 
ounce  of  water,  or  more,  seems  sometimes  to  give  considerable  com- 
fort. I  formerly  thought  very  well  of  local  mercurial  fumigations, 
but  I  have  discarded  them,  finding  mercurial  solutions  as  good,  and 
easier  to  use. 

Upon  mucous  patches,  milk -spots  of  epithelial  thickening  and 
moderate  ulceration,  nitrate  of  silver,  the  solid  or  mitigated  stick, 
sometimes  a  solution  with  a  brush,  varying  the  strength  from  gr.  j  to 
gr.  X  to  the  ounce  of  water.  Sulphate  of  copper,  as  a  mounted  pencil, 
to  be  used  lightly  by  the  patient  himself  once  a  day.  Bichloride  of 
mercury  in  solution,  about  gr.  ij  to  the  ounce,  applied  with  a  brush. 
The  acid  nitrate  of  mercury  pure,  and  applied  sparingly  with  the 
blunt  end  of  a  glass  rod.  This  I  consider  the  best  application  of  all, 
but  as  a  drawback  the  pain  it  produces  upon  some  patients  is  very 
severe,  and  lasts  several  hours.  It  need  not  be  reapplied  more  than 
once  a  week,  and  is  very  effective.  I  sometimes  order  it  for  patients 
to  use  themselves  upon  the  lesions  of  the  mouth  or  elsewhere,  reduced 
in  strength,  3  j  in  §  J  of  water. 

Upon  the  anus,  and  under  the  prepuce,  mucous  patches  and  ulcers 
are  treated  as  already  described  when  speaking  of  these  lesions  upon 
the  skin. 

1.  Mercury  by  tlie  Stomach. — This  means  must  be  adopted  in  the 
vast  majority  of  cases,  and  it  is  only  in  examples  of  rare  idiosyncrasy 
that  it  is  objectionable.  As  already  stated,  the  general  action  of  mer- 
cury taken  by  the  stomach  is  not  so  rapid  as  by  other  means.  It  may. 
however,  be  so  taken  for  any  length  of  time,  is  very  little  troublesome, 
can  be  continued  while  traveling,  and  without  making  the  patient 


570  GENERAL  TREATMENT  OF  SYPHILIS. 

conspicuous  to  his  friends,  and  it  can  be  so  used  as  to  act  as  a  tonic  as 
well  as  a  specific,  and  to  do  the  patient  no  possible  harm  while  he  is 
taking  it.* 

ScA-eral  forms  of  mercury  have  proved  themselves  by  experience  to 
be  especially  adapted  to  prolonged  use  by  the  stomach  in  syphilis  ; 
they  are  the  protiodidc,  tlie  bichloride,  blue-pill,  and  gray  powder  ; 
the  latter  has  been  used  chiclly  with  infants.  Calomel  is  usefnl  in  those 
cases  in  which  it  is  desirable  to  bring  the  patient  very  rapidly  under 
the  full  influence  of  mercury.  Administered  in  one-twclfth-grain 
doses  every  hour,  it  will  often  "touch  the  gums"  in  twenty-four  to 
forty-eiglit  hours,  and  with  safety,  for  its  prompt  discontinuance  on 
the  first  appearance  of  signs  of  salivation  prevents  the  development  of 
the  latter.  These  preparations  leave  little  to  desire,  and  among  them 
any  patient  can  bo  suited.  I  rarely  use  the  biniodide,  as  it  is  too  irri- 
tating to  the  intestine.  I  have  experimented  with  tiie  tannate,  which 
is  being  brought  forward  rather  prominently  of  late  years  in  Germany 
and  France,  but  I  do  not  find  it  better  than  the  drugs  we  already  use, 
and  the  different  preparations  vary  greatly  in  their  effect  in  my  hands. 
Gray  powder  and  blue-pill  are  good  preparations  when  the  protiodide 
proves  too  irritating  to  the  intestine,  as  it  sometimes  docs.  The  bi- 
chloride is  a  very  tonic  preparation,  especially  Avhen  combined  with 
tincture  of  cinchona,  and  is  more  prompt  than  the  others.  My  choice, 
however,  is  the  protiodide.  I  do  not  like  the  other  drugs  as  well,  for 
the  simple  reason  that  they  do  not  irritate  the  intestine  sufficiently, 
and  frequently  first  announce  that  the  patient  has  reached  the  satura- 
tion point  by  the  mouth  in  the  way  of  a  slight  touching  of  the  .gums 
rather  than  first  by  the  bowels,  as  is  the  customary  way  in  the  case  of 
the  protiodide.  This  irritation  of  the  bowels  gives  warning  that  the 
full  dose  is  reached,  and  the  patient  is  still  a  long  way  from  salivation  ; 
and  I  consider  this  an  advantage,  for  the  griping  and  diarrhoeal  effect 
can  be  controlled,  if  need  be,  for  a  time,  by  mild  opiates,  and  the  half 
or  tonic  dose  habitually  used  does  not  upset  the  bowels  at  all.  Lately 
several  enterprising  pharmaceutical  chemists  have  been  endeavoring 
to  produce  a  pure  protiodide  of  mercury,  for  the  drug  as  habitually 
made  is  very  unstable,  and  promptly  changes  in  part  into  metallic 
mercury,  with  traces  of  the  biniodide,  and  these  changes  take  i:»lace  in 
spite  of  the  exclusion  of  light  and  air.  This  alleged  pure  drug  does 
not  change  if  slightly  protected  in  a  yellow  bottle,  and  is  itself  not 
green,  but  of  a  brilliant  canary  yellow.  These  yellow  pills  I  can  not 
advocate,  and  do  not  use  often  ;  they  (as  made  in  one-sixth,  one-fifth, 
one-quarter-grain  granules)  are  too  powerful,  too  much  like  the  bin- 
iodide in  their  action.  They  irritate  the  intestine  too  much  in  most 
instances,  and  can  not  be  taken  comfortably  by  the  patient  in  sufficient 
doses.  It  is  not  important,  from  my  standpoint,  that  this  yellow  drug 
*  "The  Tonic  Treatment  of  Syphilis,"  New  York,  IS'?! 


TONIC   TREATMENT.  5Y1 

is  pure  protiodido  and  the  green  drug  an  impure  article.  The  latter 
serves  me  best,  and  I  therefore  adhere  to  it,  pure  or  impure.  A  reli- 
able, trustworthy,  uniform  preparation  is  what  is  desired — one  that  a 
patient  may  obtain  as  well  in  one  part  of  the  country  as  another. 
Such  a  preparation  I  believe  exists  in  the  French  granule  (sugar- 
coated)  of  Gamier  and  Lamoureux.  The  little  pill  keeps  for  ever  in 
all  climates,  and  all  the  loills  seem  to  be  uniform  in  their  effect.  As 
compared  in  irritative  (intestinal)  influence  with  the  yellow  granules 
of  American  manufacture,  I  find  the  latter  powerful  in  this  direction 
as  one  to  three  ;  that  is,  if  it  takes  eighteen  of  the  French  granules  a 
day  to  produce  diarrhcea,  with  pain,  six  of  the  American  will  produce 
about  the  same  irritative  effect.  When  the  patient  is  of  a  strongly 
constipated  habit  I  sometimes  employ  the  American  granules,  other- 
wise always  the  French,  when  the  protiodide  can  be  taken  at  all. 
Sometimes  even  the  French  granules  are  too  irritating,  and  occasion- 
ally a  patient  can  not  take  even  one  granule  without  feeling  its  effect 
upon  the  bowels.  In  such  case  blue  mass,  gray  powder,  or  small 
doses  of  bichloride  may  be  used  instead  of  the  protiodide  gi-anules.  I 
consider  about  one  half  of  a  grain  of  blue  mass  equal  in  effect  to  one 
sixth  of  a  grain  of  protiodide,  and  about  one  thirtieth  of  a  grain  of 
the  bichloride  to  be  an  equivalent  dose  ;  and  often  use  one  of  the  sub- 
stitutes alone  or  combined  when  the  protiodide  proves  unsuitable. 

Tonic  Metliod  of  Treatment  by  Mercury. — By  this  title  I  mean 
the  use  of  mercury  in  such  a  way  in  the  treatment  of  syphilis  by 
elimination  (persistent  long  course  of  a  specific  drug),  that  the  mer- 
cury, over  and  above  its  antisyphilitic  effect,  shall  act  as  a  tonic — 
that  is,  shall  increase  the  number  of  the  red  blood-cells,  and  the  gen- 
eral consciousness  of  health  and  vigor  in  the  patient,  I  do  not  mean 
that  mercury  cures  syphilis  because  it  is  a  tonic,  but  that  it  may  be 
used  efficiently  in  such  a  way  that  it  shall  be  a  tonic.  Even  if  it  were 
not  a  tonic,  I  should  use  it  if  it  were  the  best  drug  with  which  to 
control  the  manifestations  of  the  disease ;  but  if  it  can  (measurably) 
control  the  disease,  and  yet  not  hurt  the  patient,  so  much  the  better. 
For  more  details  of  the  tonic  treatment  I  must  refer  to  another  place.* 
The  outline  of  treatment  is  the  following  :  The  same  drug  should  be 
used  continuously  if  possible.  It  may  be  changed  occasionally  for  a 
time  to  meet  an  emergency — i.  e.,  when,  in  spite  of  the  tonic  dose,  as 
is  often  the  case,  there  suddenly  occurs  an  outcrop  of  fresh  symptoms. 
Now,  instead  of  using  the  "  full  dose,"  some  other  more  active  means 
may  be  employed,  as  bichloride  internally  or  by  injection,  fumigation, 
inunction,  etc.,  until  the  new  symptom  yields,  after  which  it  is  well 
again  to  revert  to  the  original  drug  and  fall  back  upon  the  "  tonic 
dose." 

The  standard  fractional  dose  being  selected,  preferably  in  form  of 
*  "  The  Tonic  Treatment  of  SyphiUs,"  D.  Appleton  &  Co.,  New  York,  1811. 


572  GENERAL   TREATMENT   OF   SYPniLIS. 

granules — oue  sixth  grain  of  protiodide  (one  contigrammo),  one  half 
grain  blue  mass,  one  thirtieth  grain  bichloride — it  remains  to  find  the 
"full  dose"  and  the  "tonic  dose."  No  combination  containing 
opium  can  bo  used  in  selecting  a  standard  fractional  dose.  The  diet 
and  liabit  should  be  regulated,  and  the  course  commenced  by  causing 
the  patient  to  take  one  granule  of  the  standard  (I  i)refcr  the  Garnicr 
and  Lamoureux  one-centigram  me  granule)  preparation  immediately 
after  each  meal  for  three  days — that  is,  three  a  day.  For  the  next 
three  days  he  takes  four  a  day  (one  in  the  morning,  two  at  noon,  and 
oue  at  night)  ;  then,  for  three  days,  five  a  day  (two  in  the  morning, 
one  at  noon,  and  two  at  night)  ;  then,  for  three  days,  six  a  day  (two 
in  the  morning,  two  at  noon,  and  two  at  night)  ;  then,  for  three  days, 
seven  a  day  (two  in  the  morning,  three  at  noon,  and  two  at  night)  ; 
then  eight,  and  so  on,  adding  one  granule  to  the  daily  dose  each  fourth 
day — if  there  is  reason  for  haste  I  make  it  each  third  day — until  per- 
nicious medicinal  etiects  of  mercury  begin  to  show  themselves,  which 
are,  with  the  protiodide,  usually  griping  pains  in  the  abdomen,  and 
at  least  two  free  watery  stools  a  day.  An  occasional  pain  I  pay  no 
attention  to,  and  free  movements  of  the  bowels  I  do  not  regard  so 
long  as  these  movements  are  not  watery.  Mild  colicky  diarrhcea  is 
what  I  wait  for,  and  when  this  comes  I  write  down  the  daily  number 
of  pills  required  to  produce  it,  and  name  this  number  the  "full  dose." 
Such  a  dose  may  and  usually  does  promptly  control  syphilitic  symp- 
toms, and  it  may  be  maintained,  and  its  obvious  objectionable  features 
done  away  with,  by  giving  the  patient  a  certain  number  of  half-grain 
granules  of  opium  to  take  along  with  his  protiodide.  If  blue-pill, 
gray  powder,  or  bichloride  be  used,  the  full  dose  may  first  announce 
itself  by  commencing  irritation  at  the  mouth  before  the  intestines 
show  disturbance.  This  full  dose  can  not  be  maintained  without 
injuring  the  patient  (as  I  have  proved  in  another  place),  and  it  must 
only  be  used  for  a  short  time  when  required  for  emergencies. 

Half  the  full  dose  is  the  "tonic  dose,"  and  sometimes  one  third 
the  full  dose  is  all  the  patient  requires  to  keep  him  moderately  free 
from  symptoms,  which  is  all  he  can  ask. 

If,  when  the  patient  is  first  seen,  his  symptoms  are  so  severe  that 
he  can  not  wait  to  find  his  dosage  by  this  method,  he  may  be  more 
actively  treated  by  bichloride,  by  fumigation,  or  inunction,  until 
his  active  symptoms  are  over — and  then,  after  a  rest,  his  full  dose 
may  be  sought  in  the  manner  above  described — and  his  tonic  dose 
obtained. 

Few  patients  can  take  more  than  twelve  granules  a  day  for  their 
full  dose,  and  more  stop  at  nine.  I  have  known  a  patient  go  to 
twenty.  If  a  patient  can  not  take  three  a  day  I  consider  him  unfit 
for  treatment  by  the  protiodide.  The  size  of  the  "full  dose"  varies 
greatly  for  different  individuals. 


TONIC   TREATMENT.  573 

The  patient  then  is  not  to  be  kept  at  his  full  dose.  If  he  has  act- 
ive symptoms  he  may  be  kept  at  three  quarters  of  the  full  dose,  or 
the  latter  may  be  maintained  by  opium  until  the  emergency  is  over. 
If  the  symptoms  arc  not  active,  a  rest  should  be  given  for  several  days 
until  the  ill  effects  of  the  mercury  have  entirely  subsided,  and  then 
the  ''tonic  dose"  may  be  commenced  with  the  idea  of  continuing  it 
daily,  month  after  month,  for  an  average  of  about  two  and  a  half 
years.  Under  this  dose — one  half  or  one  third  of  the  "full  dose" — 
the  patient  will  often,  but  of  course  not  always,  enjoy  better  health 
than  he  did  before  he  got  his  chancre — that  is,  he  will  eat,  drink, 
sleep,  and  work  with  greater  satisfaction  to  himself.  Truly,  he  will 
have  occasional  drawbacks  in  the  form  of  mouth-spots  and  of  out- 
cropping syphilitic  symptoms,  and  these  must  be  met  by  appropriate 
local  means  or  by  temporarily  putting  in  a  portion  or  even  the  whole 
of  the  "reserve  dose,"  to  constitute  the  "full  dose,"  protected  by 
opium  until  the  flurry  is  over. 

This  is  the  outline  of  treatment.  Under  it  intermediary  or  ter- 
tiary symptoms  may  never  appear.  When  they  do,  the  iodides  and 
vegetable  preparations  may  be  added,  the  granules  being  kept  up. 
There  is  not  any  truth  in  the  statement  that  there  is  danger  in  giving 
the  protiodide  of  mercury  in  connection  with  the  iodide  of  potassium 
on  account  of  possibility  of  poisoning  the  patient  by  the  formation 
within  the  body  of  the  biniodide  of  mercury.     I  do  it  daily. 

The  patient  may  prefer  his  medicine  at  a  single  dose,  and  it  is  not 
well  to  be  inflexible  about  the  accurate  "  tonic  dose  "  after  a  time.  I 
often  give  the  granules  for  a  year,  and  then  common  mixed  treatment 
— to  be  mentioned  presently.  But  again,  I  often  give  practically 
nothing  whatever  except  the  granules  for  the  entire  treatment  of,  in 
the  shortest  cases,  eighteen  months,  the  longest,  three  and  a  half  or 
four  years — this  being  continuous  treatment. 

When  purely  gummatous  symptoms  occur,  I  usually  stop  the  mer- 
cury entirely,  to  resume  it  for  a  time  after  the  iodides  have  controlled 
the  symptoms. 

If  intercurrent  maladies  come  on,  the  treatment  may  be  suspended 
entirely  during  their  existence,  without  ultimate  detriment  to  the  pa- 
tient. In  any  case  of  intercurrent  diarrhoea  the  tonic  dose  should  be 
suspended. 

When  something  besides  the  tonic  course  is  required,  the  bichloride 
of  mercury  may  be  given  in  a  bitter  menstruum,  increasing  until  the 
symptoms  yield,  or  some  disagreeable  result  of  mercurialization  seems 
imminent,  carrying  the  dose  to  one  eiglith  or  one  sixth  of  a  grain.* 

*  Muriate  of  ammonia  is  frequently  added  to  solutions  containing  the  bichloride,  to 
increase  the  solubility  of  the  latter,  where  large  doses  are  given.  A  saturated  solution 
of  hydrochlorate  of  ammonia  dissolves  seventeen  times  more  bichloride  than  simple 
water. 


574  GENERAL  TREATMENT  OF  SYPUILIS. 

Tlie  common  solution  in  tincture  of  bark  (or  the  elixir)  is  as  good  as 
any  that  can  be  desired  : 

IJ      Hydrarg.  bichlorid., 

Ammouii  sesquichloriil.,  ail  gr.  jss.-iij. 

Tr.  cinchoua}  co.,  §  iij. 

M.     S. :  Teaspoonful,  largely  diluted  in  water,  aftir  eating. 

Or  the  old  New  York  Hospital  formula — 

1}      Ilvdrarg.  biclilorid.,  pr.  iv. 

Tr.  ferri  sesquiehlorid.,  3  j. 

S. :  Ten  drops  in  water  after  eating — 

may  be  exhibited  with  good  effect  in  anaemic  cases  where  the  stomach 
is  not  weak,  as  in  the  earlier  outbreaks  attended  by  syphilitic  fever, 
where  a  tonic  is  particularly  required — in  some  cases  indeed  to  the 
total  exclusion  of  mercury.  When  it  is  deemed  advisable  to  give  the 
bichloride  in  pill-form,  it  may  be  combined  with  reduced  iron,  as  in 
the  followinsr : 


Hydrarg.  bichlorid., 

gr.  j. 

Ferri  redact., 

3  jss. 

Gum.  tragacanth.. 
Glycerin!, 

[q-  s. 

M. 

F.  pil.  No.  XV. 

In  an^Bmic  women  the  New  York  Hospital  formula  is  a  good  one, 
in  which  blue-pill,  gr.  ij,  is  combined  with  gr.  j  of  the  dried  sulphate 
of  iron  in  pill-form.  The  quantity  of  either  ingredient  of  the  pill 
may  be  increased  if  circumstances  require.  Finally,  the  gray  powder 
(hydrarg.  cum  creta)  may  be  employed,  increasing  from  two-grain 
doses. 

Trousseau's  suggestion  of  one-tenth-grain  doses  of  calomel  every 
one  to  three  hours  for  the  intense  early  headache  of  syj^hilis  must 
not  be  forgotten. 

In  advocating  a  methodical  course  of  mercurial  treatment  like  the 
"tonic  course,"  I  do  so  with  the  conviction  that  it  possesses  many 
merits  and  no  fault  that  I  recognize  except  one — difficulty  in  keejoing 
the  patient  up  to  his  course.  I  have  found,  however,  much  less  trouble 
with  intelligent  patientst  than  with  others,  the  objection  with  intelli- 
gent patients  being  that  they  expect  too  much  of  the  course,  and 
sometimes  become  disheartened  when  they  see  symptoms  appear,  and 
others  persist  while  they  are  taking  it.  On  this  head  they  can  be 
comforted  by  the  assurance  that  the  course  is  eliminative,  not  suppres- 
sive ;  that,  if  a  few  moderate  symptoms  persist,  local  treatment  is  a 
suitable  adjuvant ;  that,  if  new  symptoms  appear,  then  is  the  time  to 
add  the  reserve  dose,  or  part  of  it,  or  to  throw  in  some  iodide  of  potas- 
sium for  a  time.  They  can  also  be  assured  that  they  are  taking  mer- 
cury in  the  mildest  manner,  that  it  will  not  hurt  them  if  they  con- 
tinue taking  it  for  several  years,  that  it  will  not  remain  in  the  system. 


MIXED   TREATMENT.  575 

and  that  their  chance  of  positive  cure  and  escape  from  late  tertiary 
symptoms  is  exceedingly  good  under  this  method,  although  such  im- 
munity can  not  be  positively  assured  by  any  method.  My  experience 
with  the  method  now  covers  fourteen  years,  and  for  thirty  years  be- 
fore that  a  somewhat  analogous  method  was  carried  out  in  the  office 
by  Dr.  Van  Buren  before  me,  and  by  both  of  us  after  I  joined  him. 
The  results  have  been  satisfactory. 

TREATMENT    OP    LATE    SYPHILIS. 

If  there  is  no  intermediary  or  tertiary  set  of  symptoms,  as  is  often 
the  case,  there  is  never  any  positive  necessity  for  the  use  of  iodide  of 
potassium  unless  the  early  symptoms  are  severe  or  much  protracted. 
Generally,  however,  some  of  the  later  symptoms  come  to  the  surface, 
and  then  the  iodides  must  be  used — in  connection  with  mercury  in 
all  cases  excepting  those  of  pure  gummatous  deposit,  in  which  only 
the  iodides  are  required.  Wlieu  both  drugs  are  combined,  the  treat- 
ment is  called  mixed. 

Mixed  Treatment. — When  during  the  tonic  course  there  is  a  call 
on  the  part  of  the  symptoms  for  the  iodides,  they  may  be  given  while 
the  granules  of  mercury  are  continued,  or  iodides  internally  may  be 
perfectly  well  combined  with  fumigation,  or  with  the  use  of  mercury 
by  inunction,  as  practiced  at  the  hot  springs.  Often,  however,  it  is 
better  for  a  long  course  to  combine  all  the  drugs  required  in  a  single 
dose.  This  may  be  done  by  using  biuiodide  or  bichloride  of  mercury 
with  any  of  the  iodides.  The  objection  made  by  many,  myself  formerly 
among  them,  that  bichloride  of  mercury  was  converted,  in  part  at  least, 
into  biniodide  when  placed  in  solution  along  with  iodide  of  potassium, 
is  not  worth  maintaining,  I  think.  The  effects  of  the  bichloride  com- 
bination seem  to  be  generally  better  than  the  other,  and  that  consid- 
eration overpowers  all  purely  chemical  objections. 

When  iodides  are  given  in  combination,  a  little  ammonia  (Paget)  is 
often  added,  under  the  idea  that  the  effect  of  the  iodides  is  intensified, 
and  the  tolerance  of  the  patient  to  the  drug  increased.  There  is  also 
no  objection  to  combining  iron  with  the  prescrij)tion,  or  arsenic  (when 
required  either  for  the  eruption  for  tonic  purposes  or  to  make  the  pa- 
tient bear  the  iodide  better).  An  excellent  combination  of  this  sort 
for  prolonged  use  is  the  following  : 

5     Hydrarg.  chlorid.  corros.,  gr.  j-iij. 

Liq.  potassse  arsenit.,  ni  xij-l. 

Ferri  ammonio-citrat.,  3  ss.-  5  ij. 

Aquae  ammonia,  3  ss. 

Potassii  iodidi,  3  ij-  §  j. 

Syr.  aurantii  corticis,  §  jss. 

AquEE,  q.  s.  ad  f  3  iij. 
M.    S. :  Teaspoonful  in  water  three  times  a  day. 


576  GENERAL  TREATMENT  OF  SYPUILIS. 

Such  a  mixed  formula  is  not  usually  called  for,  and  those  more 
generally  useful  are  such  as  the  following  : 

TJ     Ilyilrarg.  binioiiuli,  gr.  ss.-ij. 

Aiuiuonii  iodidi,  3  ss. 

.    Totassii  iodidi,  3  ij-  3  j- 

Syr.  aurantii  corticis,  3  jss. 

Tr.  aurantii  corticis,  3  j. 

Aquae,  q.  s.  ad  3  iij. 
M.    S. :  Teaspoouful  in  water  three  times  a  dav. 

Or, 

5     Ilydrarg.  chlorid.  corros.,  gr.  j-iij. 

Sodii  iodidi,  3  ij-  3  j. 

Syr.  zingiberis,  3  ij. 

AquiP,  q.  s.  ad  3  iij. 

M.    S. :  Teaspoonful  in  water  three  times  a  day,  and  so  on,  tiic  possible  com- 
binations being  endless. 

The  Iodides. — Often  the  iodides  have  to  be  used  alone  and  pushed 
to  the  point  of  tolerance.  Also,  when  the  tonic  mercurial  course  is 
being  followed,  the  iodides  often  hare  to  be  combined  with  it.  Under 
these  and  many  other  circumstances,  it  is  better  to  prescribe  the 
iodide  of  potassium  in  the  form  of  a  saturated  solution  in  distilled 
water,  and  make  the  patient  measure  out  each  dose  into  a  conical 
(not  a  cylindrical)  minim  glass  : 

B     Potassii  iodidi,  '%  j. 

AqUcB  destillatfe,  q.  s.  ad  f  3  j.        * 

M.    S. :  A  minim  is  a  grain. 

This  method  is  an  admirable  one  when  the  dose  has  to  be  run  high. 
The  iodide  of  potassium  is  prepared  in  the  form  of  five-grain  compressed 
pills,  but  most  patients  tolerate  the  solution  better,  and  no  one  can 
take  very  large  doses  in  the  solid  form  on  account  of  tlie  irritating 
effect  upon  the  stomach. 

The  iodides  are  agents  of  the  very  highest  value  in  syphilis,  and  in 
purely  gummatous  and  many  of  the  nervous  symptoms  their  action  in 
very  large  doses  is  most  gratifying.  The  iodide  of  potassium  is  the 
most  efficient  of  the  group.  The  iodide  of  sodium  comes  next.  It  is 
not  so  soluble,  but  a  fifty-per-cent  solution  is  perfectly  stable.  It  is 
borne  better  by  the  stomach,  but  from  my  experience  I  judge  that  it 
requires  nearly  twice  as  much  of  this  drug  to  produce  an  effect  as  of 
the  stronger  iodide  of  potassium.  I  have  tested  the  iodide  of  ammo- 
nium and  the  iodide  of  calcium,  but  have  practically  discarded  them. 
The  so-called  iodide  of  starch  has  sometimes  given  me  good  service. 
This  is  a  mechanical  rather  than  a  chemical  iodide.  It  is  ordinarily 
made  as  directed  in  the  pharmacopoeia  with  raw-wheat  starch.  I  have 
had  it  made  with  cooked-rice  starch,  and  like  it  better.  It  is  well 
borne  by  the  stomach  but  disagreealjle  to  take.  It  may  be  conven- 
iently swallowed  in  capsules  containing  ten  or  even  twenty  grains,  or 
the  powder  may  be  mixed  in  water,  milk,  or  broth,  and  so  taken  it 


THE  IODIDES.  577 

does  not  dissolve.  The  iodide  of  starch  may  be  given  in  place  of  any 
of  the  iodides  in  common  use.  I  have  given  as  much  as  a  heaping 
dessertspoonful  at  a  dose.  The  tincture  of  iodine  in  starch-water  I 
have  abandoned  for  the  prepared  iodide  of  starch.  The  disagreeable 
after-taste  left  in  the  mouth  by  iodide  of  potassium  may  be  best 
masked  by  peppermint  or  chewing  liquorice-root.  At  the  time  of  tak- 
ing the  drug  the  sirup  of  currants  or  orange-peel  is  probably  the  best. 

The  best  time  to  take  the  iodides  is  during  the  third  hour  after 
eating,  when  the  contents  of  the  stomach  are  neutral  and  yet  tlie  organ 
is  not  empty.  Even  on  an  emjjty  stomach  the  drug  goes  well  if  very 
largely  diluted  in  water ;  or,  better,  an  efEervescent  mineral  water 
(Vichy  or  carbonic-acid  water — soda  water)  ;  or,  better  still,  in  milk.* 

The  Dose  of  the  Iodides. — There  is  no  limit.  I  have  given  two 
and  a  half  ounces  daily.  I  have  known  of  even  larger  daily  doses  be- 
ing given  at  the  hot  springs.  If  the  diagnosis  is  correct,  and  if  the 
iodides  in  excess  are  indicated,  I  know  nothing  which  ought  to  arrest 
the  increase  in  the  dose  except  a  subsidence  of  the  symptoms — unless 
the  iodides  themselves  are  doing  harm — of  which  I  shall  speak  pres- 
ently. I  have  read  somewhere  of  a  death  produced  by  one  enormous 
dose  of  the  iodide  of  potassium,  but  I  can  not  find  the  reference.  I 
believe  the  dose  was  one  ounce,  and  had  not  been  worked  up  to — ^but 
this  is  only  an  impression. 

The  Bad  Effects  of  the  Iodides. — These,  for  the  most  part,  are 
irritations  of  the  cutaneous  structures  or  mucous  membranes.  They 
are  so  strongly  pronounced  in  some  patients  that  they  can  not  possibly 
be  made  to  take  the  drugs  very  freely.  Any  one  will  sooner  or  later 
suffer  from  the  medicinal  effects  of  the  iodides  if  he  takes  enouffh  of 
the  drug,  but  the  variation  in  this  particular  is  very  wide.  I  knew 
one  medical  gentleman  who  at  one  time  in  his  life  could  not  touch  his 
tongue  to  the  moistened  cork  of  a  bottle  containing  an  iodide-of-potas- 
sium  solution  without  feeling  the  effects  for  a  day  upon  the  mucous 
membrane  of  his  nose  ;  and  another  gentleman  who  experienced  mild 
symptoms  of  iodism  if  the  tincture  of  iodine  touched  his  skin — at 
least,  he  affirmed  the  fact — and  he  was  a  physician  of  high  intelli- 
gence. On  the  other  hand,  I  have  seen  a  patient  take  an  ounce  a  day 
and  suffer  no  ill  effects,  not  even  acne,  although  the  metallic  taste  in 
the  mouth  is  always  much  complained  of  when  the  dose  runs  high. 
The  bad  effects  of  the  iodides  f  are  five  :  J 

*  Keyes,  "New  York  Medical  Journal,"  April  25,  1885,  p.  467. 

f  The  supposed  power  of  iodine,  long  administered,  to  cause  atrophy  of  the  testicles 
(the  breast  in  the  female),  and  abolish  sexual  vigor,  is  purely  hypothetical.  Temporary 
diminution  of  sexual  appetite  seems  occasionally  to  depend  upon  the  internal  use  of 
iodine,  but  the  abolition  of  the  power,  or  atrophy  of  the  testicle,  never — although  syphilis 
may  undoubtedly  cause  both  the  latter. 

X  "L'lodisme,"  by  Dr.  Elisabeth  N.  Bradley,  Paris,  ISSv,  is  an  excellent  monograph 
covering  the  general  subject. 
37 


578  GENERAL   TREATMENT   OF   SYRUILIS. 

1.  Possible  iudircct  causation  of  salivation. 

2.  lodism. 

3.  Irritation  of  mucous  membranes. 

4.  Cutaneous  eruptions. 

5.  Anajtnia  with  nervous  prostration  and  debility. 

6.  Albuminuria. 

1.  Salivafion. — A  moderate  amount  of  tenderness  in  the  mouth, 
soreness  of  the  gums  at  the  line  of  the  teeth,  and  increase  of  salivary 
flow,  is  complained  of  occasionally  by  persons  taking  iodic  preparations. 
I  have  never  seen  such  salivation  run  iiigh  or  be  more  than  very  mod- 
erately annoying.  It  has  been  alleged,  with  cases  in  support,  that  the 
iodides  may  suddenly  make  mercury,  lying  peacefully  in  the  system, 
active,  and  thus  cause  salivation.  I  have  not  seen  this,  and  it  must 
be  uncommon.  Indeed,  there  are  those  who  state  that  iodides  act  by 
liberating  mercury  and  making  more  efficient  that  which  is  being 
taken.  Although  there  may  be  a  measure  of  truth  in  this  it  is  not 
strictly  true,  because  many  cases  of  early  syphilis  are  helped  by  the 
iodides  when  they  have  taken  no  mercury ;  and  I  have  seen  cases  of 
pure  gummata  in  patients  who  had  taken  no  niA'Cury  early  in  their 
course,  and  who  none  the  less  improved  rapidly  under  the  iodides. 

2.  lodism. — A  peculiar  jioisonous  effect  is  produced  upon  some  pa- 
tients by  the  use  of  iodine,  especially  in  the  form  of  iodides.  The 
symptoms  are  general  irritation  of  the  nerves,  with  depression  ;  the 
ears  ring,  the  head  aches,  neuralgic  pains  are  felt  deep  in  the  bones 
and  muscles.  There  is  more  or  less  general  torpor,  with  physical  and 
mental  depression.  This  affection  is  rare.  It  may  occur  from  the 
least  touch  of  iodine,  or  large  quantities  may  be  required  to  produce 
it.  It  occurs  with  or  without  irritation  of  the  cutaneous  or  mucous 
expansions. 

3.  General  irritation  of  more  or  less  of  the  mucous  expansions  of 
the  body,  with  perhaps  some  nervous  phenomena,  headache,  pains  in 
the  bones  (iodism).  In  mild  cases  this  takes  the  form  of  "catarrh," 
or  a  simj^le  cold.  A  sharj)  coryza  sets  in,  with  sneezing  and  a  plenti- 
ful watery  discharge  from  the  nose,  perhaps  with  reddened  conjunc- 
tivae and  streaming  eyes.  Bumstead  mentions,  in  rare  instances,  loss 
of  vision,  due  apparently  to  sub-retinal  effusion.  The  lining  of  the 
frontal  sinuses  may  be  hyperasmic  and  swollen,  occasioning  consider- 
able pain.  The  fauces  and  mucous  lining  of  the  lungs  participate  'u\ 
these  hyperaemic  and  secretory  changes  occasionally.  Tiie  symptoms 
sometimes  reach  a  high  grade,  from  swelling  and  oedema.  A  marked 
increase  of  the  salivary  flow  is  observed.  J.  S.  Cohen,*  of  Philadelphia, 
has  seen  two  cases  in  which  he  believes  that  oedema  of  the  larynx  was 
caused  by  the  use  of  large  doses  of  iodide  of  potassium. 

The  stomach  and  intestines  suffer  less  often  than  the  nasal  and 

*  "The  Hospital  Gazette,"  August  9,  18'79,  p.  3S3. 


BAD   EFFECTS   OF   THE   IODIDES.  5Y9 

bronchial  membranes,  if  the  precautions  arc  observed  of  never  giving 
the  iodides  solid,  except  in  small  quantity,  during  or  immediately  after 
a  full  meal.  AVhen  a  large  quantity  is  given,  it  must  always  be  in  solu- 
tion largely  diluted,  and  taken  two  or  three  hours  after  a  meal,  or  even 
upon  an  empty  stomach.  Sometimes  a  patient  will  take  his  dose  just 
as  well  directly  after  a  meal,  and  then  for  simple  convenience  he  may 
as  well  do  so.  In  irritable  cases,  however,  a  neglect  of  these  precau- 
tions not  infrequently  produces  pain  in  the  pit  of  the  stomach,  loss  of 
ai)petite,  griping,  diarrhoea.  Mild  attacks  usually  subside  even  with 
a  judicious  continuance  of  the  remedy.  But  in  rare  cases  the  symp- 
toms are  so  violent  that  the  drug  has  to  be  discontinued. 

The  iodide  of  sodium  is  much  less  irritating  than  the  iodide  of 
for  it  with  favorable  effect, 
potassium,  as  has  been  already  stated,  and  may  often  be  substituted 

4.  Cutaneous  Eruptions.  * — There  are  four  types  of  eruj)tions  caused 
by  iodic  preparations.  These  are,  in  the  order  of  their  relative  fre- 
quency, acne,  erythema  (more  or  less  eczematous),  purpura,  and  a 
bullous  eruption. 

(1)  Acne. — A  few  pustules  or  papulo-pustules  of  acne  (simplex  or 
indurata)  generally  appear  during  a  course  of  the  iodides.  Their 
favorite  site  is  about  the  forehead,  cheeks,  shoulders,  back,  buttocks, 
and  extensor  aspect  of  the  limbs.  They  are  usually  unirnportaut,  but 
sometimes  they  occur  in  profuse  crops,  covering  nearly  the  whole  body, 
and  are  then  painful  and  unsightly.  With  acne  may  be  associated 
large  tuberculo-pustules  and  boils — ecthyma. 

(2)  Erythema. — Iodic  erythema,  as  commonly  observed,  covers  the 
slopes  of  the  nose  and  portions  of  the  cheeks  and  forehead.  It  is  fol- 
lowed by  branny  desquamation.  It  may  occur  upon  other  surfaces, 
isolated  or  in  large  patches,  particularly  on  the  forearms.  It  is  some- 
times attended  by  papulation.  Papules  may  appear,  not  acneic  and 
not  surrounded  by  erythema.  The  erythema  may  run  on  to  eczema 
about  the  face  and  scalp.  Mercier  mentions  a  case  where  in  the  same 
patient,  on  two  occasions,  small  doses  of  the  iodide  of  potassium  pro- 
duced a  severe  eruption  of  eczema  rubrum  over  the  whole  body. 

(3)  Purpura  may  be  caused  by  large,  sometimes  by  moderate  doses 
of  the  iodides  ;  chiefly  in  debilitated,  anaemic  subjects,  suffering  from 
syphilitic  cachexia  and  tertiary  lesions.  It  occurs  sometimes  in  pa- 
tients who  seem  to  be  well  nourished.  The  best-marked  cases  of  pur- 
pura hgemorrhagica,  in  the  author's  experience,  are  encountered  in 
connection  with  advanced  tertiary  disease,  as  in  giving  large  doses  of 
iodide  for  nervous  syphilis.  Iodic  purpura  rarely  gets  above  the 
knees.  It  is  accompanied  by  some  oedema.  It  may  occasionally 
reach  the  thighs,  or  be  seen  upon  the  hands.     It  often  ceases  to  ap- 

*  An  excellent  study  of  this  subject  by  Pellizzari  appeared  in  the  "  Archives  of  Der- 
matology," July,  1881,  p.  264. 


580  GEXERAL  TREATMENT  OF  SYPHILIS. 

pear  upon  cli.^contimiing  the  drug,  or  change  of  air.  The  exliibition 
of  cod-liver  oil,  astringent  preparations  of  iron,  and  other  hygienic 
and  tonic  measures,  are  indicated.  Purpura  due  to  the  iodides  was 
noticed  by  Kicord.  and  written  about  by  him  as  early  as  1842. 

(4)  A  ju'cidiar  bullous  eruption  due  to  the  ingestion  of  the  iodide 
of  potassium  has  been  noted  by  many  observers  who  have  written  ex- 
haustively about  it.  Eicord  first  described  it  as  a  rui>ia.  I  have  seen 
only  two  cases  in  which  tliere  were  groups  of  bull;v  scattered  over  the 
body,  mainly  upon  the  trunk  and  face,  and  a  moderate  number  of 
separate  single  lesions.  Most  of  the  bulhi^  were  umbilicated  at  first, 
and  some  of  them  readied  a  large  size.  The  possibility  of  confound- 
ing it  with  varioloid  has  been  pointed  out.  Its  course,  however,  is 
different,  and  any  attentive  observer  can  not  fail  soon  to  refer  it  to  its 
true  source.  Among  the  writers  who  have  noted  it  are  Bradbury, 
Virchow,  Bumstead,  Boinet,  Pinger,  Cazenave,  Hutchinson,  Taylor, 
Fournier,  Duhring,  Hyde,  T.  Fox,  Finney,  Duckworth,  Farquharsen, 
Pellizzari,  Van  Ilarlingen,  Morrow,  Tilden,  and  others.  Thin  *  has 
described  it  pathologically.  Hyde  \  intimates  that  all  the  iodic  bul- 
lous eruptions  may  bo  grouped  into  three  sub-forms  :  1.  Simple  bulla, 
seen  in  the  old  and  cachectic.  2.  A  rarer  polymorphic  form — bulla3 
mingled  with  papules,  macules,  and  tubercles.  3.  A  quasi-bullous 
eruption,  first  described  by  T.  Fox,  and  resembling  variola — a  rare 
form  found  on  the  face,  backs  of  the  arms,  and  forearms — a  semi-solid 
umbilicated  lesion  which  does  not  collapse  on  puncture,  being  filled 
with  insi)issated  grumous  contents.  These  lesions  shrivel  or  dry  to 
a  crust  when  the  use  of  the  iodide  is  suspended. 

5.  Anmmia  with  Nervous  Prostration. — I  have  seen  several  cases  in 
which  patients  long  under  treatment  for  severe  nervous  lesions  due  to 
syphilis,  by  continuing  their  treatment  too  long  and  at  too  high  a  dose, 
gradually  became  anaemic  without  losing  flesh,  restless,  nervous,  de- 
spondent, tremulous,  unable  to  eat,  and  apparently  too  weak  to  do 
any  work.  I  have  seen  two  patients  from  this  cause  give  up  work  and 
one  of  them  pre^^are  to  die.  One  could  not  sign  his  name,  so  weak 
and  unsteady  was  he,  and  yet  both  recovered  in  a  few  weeks  after  leav- 
ing off  the  iodide,  going  away  from  town,  and  resorting  to  general  tonic 
measures  :  milk,  phosphates,  rest,  and  the  like. 

6.  Albuminuria. — I  have  also  seen  more  than  once  very  mild  albu- 
minuria with  hyaline  casts  coincide  with  the  use  of  very  large  doses 
of  the  iodide  of  potassium.  Xo  symptoms  of  ordinary  albuminuria 
attended  this  state  of  affairs,  and  the  albumen  and  casts  promptly  dis- 
appeared on  leaving  off  the  drug.  This  phenomenon  is  not  at  all  com- 
mon in  my  experience.  Most  patients  support  the  largest  doses  they 
can  tolerate  without  showing  any  sign  on  the  part  of  the  kidneys.     I 

*  "  Medico-chir.  Trans.,"  vol.  Ixii,  1879,  p.  189. 

\  "  Journ.  of  Cutaneous  and  Venereal  Diseases,"  December,  1886,  p.  853. 


DURATION   OF  TREATMENT.  581 

do  not  believe  that  permanent  kidney  disease  can  be  caused  by  the 
continued  or  excessive  use  of  the  iodide  of  potassium. 

Means  by  wMcTi  the  Bad  Effects  of  the  Iodides  may  he  diminished. 

When  the  stomach  is  to  such  a  degree  irritated  that  the  iodides 

can  not  be  taken  at  all,  sometimes  in  emergency  the  large  intestine  may 
be  used  for  a  few  days.  I  have  thrown  in  moderate  doses  in  this  way, 
well  diluted,  and  I  believe  with  good  effect,  but  the  intestine  soon  be- 
comes rebellious.  When  the  irritative  effects  of  the  iodides  run  too 
hio-h,  the  dose,  if  allowable,  should  be  stopped  for  a  few  days,  and  then 
resumed  in  milk  or  largely  diluted  in  an  effervescent  alkaline  mineral 
water.  At  the  same  time  there  may  be  added  some  acetate  of  potash 
to  the  solution,  which  by  acting  upon  the  kidney  carries  off  the  offend- 
ing drug.  Diluent  mineral  waters  (Bethesda,  Poland)  may  be  added, 
Pellizzari  states  that  in  most  of  the  bad  cases  of  the  evil  effects  of  the 
iodides  the  urinary  secretion  was  affected,  and  that  in  the  most  severe 
cases  the  urine  contained  albumen.  The  tincture  of  belladonna  com- 
bined with  the  iodides  in  moderate  doses — ttix  with  each  dose — seems 
to  have  a  good  effect  sometimes.  Moderate  doses  of  arsenic  certainly 
moderate  the  bad  effects  of  the  iodides.  Quinine  is  said  to  aggravate 
them,  but  I  have  not  observed  it. 

Iodoform  has  been  given  as  a  substitute  for  the  iodides.  Hill 
praises  it  in  small  doses  for  gumma  of  the  tongue.  I  have  used  it  in 
small  and  large  doses,  and  have  nothing  to  say  in  its  favor.  Moreover, 
iodoform  is  sometimes  poisonous.  Death  has  been  caused  by  it  when 
used  as  a  dressing  upon  a  wound.  It  is  accused  of  causing  feeble  ac- 
tion of  the  heart,  coma,  nervous  disturbances  amounting  to  mania, 
urticaria,  albuminuria,  erythematous  rashes,  etc.  It  has  caused  death 
when  administered  internally  (Oberlander),  the  maximum  dose  being 
gr.  xijss.  in  a  pill,  and  altogether  too  much  harm  may  come  of  it  if 
used  freely  to  make  such  a  course  wise,  while  the  good  coming  from 
its  use  in  moderate  and  small  doses  can  not  be  attested  by  my  experi- 
ence. E.  W.  Taylor,*  in  an  excellent  paper,  has  recently  summarized 
"what  is  known  about  the  evil  effects  of  iodoform,  used  locally. 

DUEATION    OF    TREATMENT, 

The  duration  of  the  virulence  of  the  disease  is  believed  to  subside 
in  the  third  year,  and  therefore  the  rational  period  during  which  to 
maintain  continued  treatment  is  about  the  same.  In  other  words,  it 
is  fairly  logical  to  assume,  since  syphilis  is  a  malady  continually  viru- 
lent for  a  given  period,  continually  present  during  that  time  with 
alternations  of  lull  and  outbreak,  that  treatment  should  be  the  use  of 
some  means  that  shall  control  the  symptoms  without  injuring  the 
patient,  that  this  means  shall  be  continued  during  the  whole  period 

*  "  New  York  Medical  Journal,"  October,  1887. 


5S2  GENERAL  TREATMENT  OF  SYPniLIS. 

of  vimlence — in  moderation  thirins:  the  Inlls.  in  greater  energy  during 
the  outbreaks  of  symptoms.  Such  a  rational  course  is  the  "  tonic 
treatment "  I  have  advocated.  Cases  generally  do  well  under  it  if 
sufficient  trouble  is  taken  to  maintain  it.  There  arc  two  classes  of 
cases  that  apply  for  treatment  : 

1.  The  patient  who  comes  with  syphilitic  chancre. 

3.  The  patient  who  comes  with  a  late,  obstinate  form  of  disease, 
after  perhaps  years  of  apparent  health. 

1.  The  patient  who  comes  with  chancre  should  be  gently  urged 
until  his  **  full  dose ''  of  mercury  is  found,  llis  "  tonic  dose " 
should  then — as  soon  as  the  urgency  of  his  symptoms  will  allow — be 
continued  unremittingly  until  some  reason  appears  for  a  change. 
Moderate  local  lesions  upon  the  mouth  or  elsewhere  should  be  treated 
locally  as  they  appear.  When  a  sufficiently  severe  outcrop  of  new 
symptoms  appears,  it  should  be  treated  by  the  "full  dose"  if  required, 
or  by  the  temporary  exhibition  of  the  iodides  along  with  the  mer- 
curial dose.  This  is  to  be  continued,  with  general  tonic  and  hygienic 
adjuvants,  for  eighteen  months.  If  then  there  has  been  no  symp- 
tom of  syphilis  present  for  a  year,  treatment  may  be  stopped  until  u 
new  outcrop  appears,  if  it  ever  does.  In  ordinary  cases,  the  course  is 
pushed  to  two  or  three  j^ars,  until  there  has  been  a  period  of  six  months 
in  which  there  has  appeared  no  symptom  of  syphilis — moderate  sore 
mouth  in  smokers  may  be  disregarded  in  making  this  estimate.  After 
such  a  healthy  interval  coming  on  after  a  period  of  one  year  from 
chancre,  continuous  treatment  may  be  stopped.  The  patient  is  then 
watched,  and  new  short  courses  instituted  if  outbreaks  appear,  the 
course  being  kept  up  for  a  considerable  period  after  the  symptoms 
have  been  overcome  by  treatment,  such  treatment  being  usually  mixed. 

This  is  the  treatment  by  elimination  or  by  extinction,  and  I  have 
made  its  bounds  as  definite  as  the  case  allows,  but  absolute  accuracy 
is  impossible.  It  is  impossible  to  say  to  a  given  patient  after  he  has 
followed  this  course  that  he  will  never  have  a  relapse  ;  but  he  can  be 
told  that  he  has  all  the  guarantee  that  medicine  can  afford  him,  and 
that  if  he  does  have  late  symptoms  the  great  probability  is  that  they 
will  be  mild,  and  it  is  almost  a  certainty  that  they  will  promptly  yield 
to  a  mixed  treatment. 

2.  IMiere  the  jyatient  first  comes  for  treatment  ivith  serious  or  ob- 
stinate disease  which  has  come  on  at  a  late  period  after  chancre,  there 
will  be  generally  found  to  blame,  either  :  1.  The  gouty  constitution. 
2.  The  scrofulous  diathesis.  3.  Intemperance,  excess,  or  misery — in 
short,  bad  hygiene  ;  or,  4.  A  short  mercurial  treatment,  at  fi-st,  per- 
haps carried  to  salivation,  which,  in  the  treatment  by  extinction,  is 
always  to  be  avoided. 

The  proper  course  to  pursue  with  such  a  case  is  to  adopt  a  treat- 
ment suited  to  the  lesion,  mixed  or  iodide  alone,  and  to  use  it,  aided 


THE  SYPIIILIDES.  533 

by  hygiene,  until  the  lesion  has  disappeared  ;  then  to  commence  a 
course  of  mixed  treatment,  and  continue  it  mildly  for  a  year  or  more, 
watching  for  relapse  ;  finally,  to  terminate  with  a  mild,  pure  mercurial 
course,  extending  over  some  months.  This  seems  to  be  the  most  bene- 
ficial course,  but  in  old,  obstinate  cases  it  will  not  always  prevent  subse- 
quent outbreaks.  In  such  cases  the  main  reliance  is  in  tonics,  hygiene, 
and  the  symptomatic  treatment  of  the  outbreaks.  It  must  be  remem- 
bered that  mercury  has  power,  more  or  less  marked,  over  all  shades 
and  dates  of  syphilis.  .  It  is  useful  in  the  tertiary  stage,  although  un- 
doubtedly not  so  useful  as  in  the  secondary. 


CHAPTEE  yi. 

SYPHILIS  OF  SKm  AND  MUCOUS  MEMBRANES. 

Syphilides,  Secondary  and  Tertiary.— The  Secondary  Syphilides.— Concomitant  Symptoms  on  Mu- 
cous Membranes. 

The  Syphilides  are  those  manifestations  of  general  syphilis  found 
upon  the  cutaneous  envelope.  There  are  two  groups,  the  secondary 
and  the  tertiary. 

Those  occurring  in  secondary  syphilis  are  : 

1.  Roseola.  5.  Bullous  syphilide. 

2.  Papular  syphilide.  6.  Vesicular  syi^hilide. 

3.  General  pustular  syphilide.        7.  Squamous  syiDhilide. 

4.  Pigmentary  syphilide.  8.  Tubercular  syphilide. 
With  these  occur  on  the  mucous  membranes  : 

1.  Erythematous  patches.  3.  jMucous  patch.es. 

2.  Ulcers.  4.  Scaly  patches. 

These  are  all  general  eruptions,  except  the  pigmentary  and  scaly 
syphilides,  and  they  belong  to  the  group  called  secondary,  about  in  the 
order  in  which  they  are  given.  Thus  the  roseola  and  papular  syphilide 
always  appear  early ;  the  tubercular  and  scaly  syphilide  always  late. 
The  former  require  mercury  alone  for  their  removal ;  the  latter  demand 
a  mixed  treatment,  a  combination  of  the  iodide  of  potassium  with 
mercury,  to  insure  the  most  prompt  and  effective  action. 

The  syphilides  which  belong  to  the  tertiary  stage  of  the  disease  are  : 

1.  Ecthyma.  4.  Tertiary  ulcerations. 

2.  Rupia.  5.   Gummy  tumor. 

3.  Groups  of  pustules. 

With  these  occur  on  the  mucous  membranes  : 

1.  Mucous  patches.  3.  Deep  chronic  ulcers. 

2.  Scaly  patches.  4.  Destructive  gummv  ulcerations. 


584  SYnilLIS   OF  SKIN   AND   MUCOUS  MEMBRANES. 

Tliese  (tertiary)  affections,  it  will  be  noticed,  are  none  of  tliem  gen- 
eralized. Tiiey  all  occur  in  patches.  Tlicv  will  bo  considered  later. 
The  concomitant  symptoms  of  the  frrouj)  are  atTections  of  the  bones,  of 
the  larynx,  of  the  internal  organs,  and  nervous  syphilis. 


SECONDARY   SYPHILIDES. 

1.  EosEOLA. — Tins  is  an  erythema,  or  simple  redness,  occurring  in 
small,  flat  patches  or  blotches  of  irregularly  crescentic  or  circular  form 
and  slightly  indented  margins,  each  blotch  varying  from  the  size  of  a 
split  pea  to  that  of  a  copper  penny.  Occasionally  the  blotches  become 
confluent.  Instead  of  being  flat,  the  patches  of  eruptions  may  be  raised 
above  the  level  of  the  surrounding  skin  by  the  presence  of  minute 
papilla?  upon  the  reddened  area.  The  patches  of  roseola  resemble 
exactly  what  would  be  an  exaggeration  of  the  mottling  (marbling)  of 
the  integument,  which  any  fair-skinned  individual  may  observe  faintly 
upon  his  own  person  by  exposing  the  abdomen  to  cold  air  for  a  few 
moments.  This  erythema  is  the  lesion  proi)er,  but,  following  the  rule 
of  polymorphism  in  syphilitic  eruj)tions,  it  is  customary  to  find  other 
lesions  besides  the  erythema,  such  as  jiustules  leaving  scabs  in  the 
hair,  and  pustules  and  papules  elsewhere,  scattered  through  the  erup- 
tion, especially  about  the  head  and  face.  The  patches  of  erythema  at 
first  disappear  entirely  upon  pressure ;  but,  where  the  eruption  has 
been  intense  or  of  long  duration,  a  faint,  tawny,  yellowish-brown  stain 
is  left  after  pressure  (pigmentation),  which  indeed  outlasts  the  erup- 
tion and  is  removed  only  by  time.  A  small  amount  of  fine  desquama- 
tion attends  the  disappearance  of  the  eruption  in  Avell-marked  cases. 

This  exanthem  is  usually  the  first  to  appear  after  chancre,  generally 
at  about  six  weeks,  sometimes  three  weeks,  occasionally  after  several 
months,  but  rarely  after  the  fourth.  Its  advent  usually  coincides  with 
the  secondary  engorgement  of  the  lymphatic  glands.  It  often  comes 
on  slowly,  and  may  never  be  observed  by  the  patient  until  his  attention 
is  attracted  to  it  by  his  physician,  or  it  may  be  called  out  rapidly  by 
the  heat  of  a  bath,  by  a  cold,  or  other  exciting  cause.  If  the  jiatient 
have  had  no  syphilitic  fever,  he  is  less  likely  to  have  noticed  the  erup- 
tion. When  it  comes  on  slowly  the  chest  and  flanks  are  first  invaded, 
and  an  inspection  of  these  surfaces  with  the  light  shining  obliquely 
across  them  will  reveal  sometimes  the  beginnings  of  a  roseola,  as  yet 
invisible  to  casual  inspection.  In  rapid  cases  twenty-four  hours  are 
sufficient  to  cover  the  whole  body  with  the  eruption,  including  even  a 
few  blotches  on  the  palms  and  soles.  In  perhaps  the  majority  of  cases 
the  eruption  is  confined  to  those  portions  of  the  skin  covered  by  cloth- 
ing, the  hands  and  face  escaping,  or  being  so  faintly  marked  as  not  to 
attract  attention. 

When  roseola  comes  on  early,  it  lasts  from  one  to  six  weeks  ;  when. 


ROSEOLA— PAPULAR   SYPIIILIDE.  585 

however,  it  first  appears  some  montlis  after  cliancrc,  it  usually  lasts 
several  months.  Treatment  greatly  influences  its  duration.  Kclapse 
occasionally  occurs. 

Diagnosis. — Patients  with  syphilophobia  arc  apt  to  mistake  the 
natural  marbling  of  the  skin  produced  by  cold  for  syphilitic  roseola. 
Heat  causes  this  marbling  to  disappear.  Non-specific  roseola  is  at- 
tended by  some  positive  febrile  symptoms,  often  by  nausea,  disappear- 
ing when  the  eruption  comes  out.  The  latter  runs  a  rapid  course.  It 
is  more  frankly  inflammatory  than  the  syphilitic  roseola,  and  occurs 
chiefly  in  children.  Copaibal  roseola  is  frankly  inflammatory,  usually 
itches,  sometimes  excessively.  The  history  shows  the  ingestion  of 
copaiba  (of  which  the  urine  smells),  and  abstinence  from  the  balsam 
effects  a  speedy  cure.  Urticaria  occurs  in  raised  patches,  and  itches 
greatly.  The  concomitant  symptoms  distinguish  measles.  The  non- 
inflammatory character  of  syphilitic  roseola,  its  lack  of  itching,  and 
the  accompanying  indolent  engorgement  of  the  lymphatic  glands,  ren- 
der its  diagnosis  easy.  When  itching  is  complained  of  with  syphilitic 
roseola,  pediculi,  urticaria,  or  some  accidental  eruptions  are  to  be  sus- 
pected. 

2.  Papular  Syphtlide. — This  eruption  may  follow  a  roseola,  or  a 
roseola  may  be  transformed  into  a  papular  eruption,  or  the  latter  may 
be  the  first  eruptive  outbreak  observed  after  chancre.  The  papules 
constituting  the  initial  lesion  may  be  miliary  in  form  (like  those  seen 
on  the  spots  of  roseola),  in  which  case  they  are  often  early  surmounted 
by  a  minute  vesicle.  The  papule  is  often  larger,  but  acuminated,  or 
it  may  be  broad  and  flattened  (this  is  a  common  form),  about  the  size 
and  shape  of  a  split  pea  (lenticular)  ;  or,  finally,  this  last  form  of 
papule  is  sometimes  greatly  exaggerated,  reaching  the  size  of  a  penny. 
The  type  varieties,  then,  of  papule  in  the  earlier  general  papular  syphi- 
lide  are  two,  the  acuminated  and  the  flat.  The  general  characteristics 
of  the  eruption  are  the  same  in  each.  The  papular  syphilide  is  super- 
ficial and  precocious. 

The  color  at  first  is  rosy,  but  soon  darkens  to  the  purplish  hue  of 
syphilis.  Pressure  removes  the  color  at  first,  but  later  some  pigmenta- 
tion occurs,  and  then  pressure  is  no  longer  effective.  This  final  tawny 
coloration  often  outlasts  all  prominence  of  the  papule.  Desquamation 
sets  in  early.  Fine  scales  become  detached,  especially  around  the  base 
of  each  papule,  forming  a  sort  of  little  ruffled  border  of  white.  Biett 
considered  this  circular  desquamation  of  the  base  of  the  papule  of  great 
diagnostic  value.  It  occurs,  however,  occasionally  in  the  case  of  large 
non-syphilitic  papules.  Sometimes  the  desquamation  is  so  consider- 
able over  closely-grouped  broad  papules  that  a  diagnosis  with  squa- 
mous syphilide  becomes  difficult.  One  form  of  papular  syphilide  is 
peculiar  :  Broad,  flat  papules  appear,  scattered  irregularly,  esjjecially 
seen  about  the  face,  forehead,  and  neck,  and  on  the  scalp.     Each  pap- 


586  SYPUILIS   OF   SKIN   AND   MUCOUS   MEMBRANES. 

iile  is  covered  by  a  thin,  3'ello\visli,  superficial  scale,  like  a  scab,  raised 
at  the  borders,  and  distinctly  dej)rcssed  centrally.  The  raised  edge  is 
sometimes  distended  by  a  slight  amount  of  serum,  the  whole  looking 
like  a  flattened,  partly  desiccated  bulla.  Sometimes  each  lesion  is  sur- 
rounded by  a  reddened  (livid)  areola.  Shortly  the  large  superficial 
scale  becomes  detached,  the  papule  pales,  flattens,  disappears,  and 
leaves  no  scar. 

The  papular  syphilide,  though  general,  is  usually  most  marked  at 
the  back  of  the  neck,  on  the  forehead,  back,  and  flanks.  There  is  no 
pain  or  itching  with  this  eru})tion.  Scabs  in  the  hair  are  likely  to 
coincide  with  it,  and  the  indolent,  engorged  post-cervical  and  epi- 
trochlcar  ganglions  are  rarely  absent.  The  eruption  may  come  before 
the  third  week  from  chancre,  or  after  the  fourth  month.  Its  dura- 
tion is  from  three  to  eight  weeks  ;  it  may  be  prolonged  for  months  by 
the  recurrence  of  successive  crops  of  papules. 

Diaynoais. — A  papular  syphilide  is  liable  to  be  confounded  with 
two  eruptions  only.  (1)  When  the  acuminated  papules  are  few,  and 
scattered  about  the  temples  and  over  the  forehead,  they  greatly  re- 
semble a  form  of  acne  seen  in  middle  age  upon  rheumatic  subjects. 
The  syphilitic  eruption  may  be  usually  distinguished  by  a  certain 
amount  of  pigmentation  around  the  older  papules,  a  feature  not  ob- 
served in  acne.  (2)  The  flat  papules,  few  in  number,  livid  in  color, 
and  attended  by  no  itching,  situated  over  the  backs  of  the  hands, 
wrists,  forearms,  and  sometimes  extensively  over  the  body,  and  consti- 
tuting one  of  the  forms  of  lichen  planus  seen  on  rheumatic  subjects, 
are  very  liable  to  be  mistaken  for  syphilitic  lesions.  The  patches, 
however,  are  more  irregular  in  shape  and  size,  and  often  present  a 
slight  umbilication  (without  desquamation)  at  some  period  of  their 
course,  which,  together  with  the  history  and  lack  of  concomitant 
phenomena,  serves  to  distinguish  this  affection  from  a  syphilide. 
With  the  papular  syphilide  are  apt  to  coexist  scabs  in  the  hair,  en- 
gorged ganglia,  perhaps  patches  of  erythema  and  pustules  occasionally, 
and  pretty  certainly  mucous  patches,  erythema  or  ulceration  of  some 
mucous  membrane,  especially  that  of  the  fauces.  Small,  circular  red- 
dened spots  on  the  palms  and  soles  are  also  a  very  constant  accompani- 
ment of  a  generalized  papular  syphilide.  These  are  attempts  at  papu- 
lation aborted  by  the  thickened  epithelium.  They  appear  as  circular 
depressions,  reddened  centrally  and  partly  deprived  of  epithelium, 
which  latter  is  undermined  at  the  edge  of  each  depression  as  a  whit- 
ened, fringed  circle.  Several  of  them  may  usually  be  found  on  each 
palm.  An  exactly  similar  condition  is  sometimes  seen  on  the  palm 
after  an  attack  of  lichen  urticatus  of  the  extremities.  The  severe 
itching  attending  the  latter  eruption  insures  against  error  of  diagnosis. 
This  affection  of  the  palms  is  sometimes  described  as  syphilitic  psoria- 
sis.    It  is  more  justly  an  aborted  papular  syphilide,  or  results  from 


GENERAL  PUSTULAR  SYPHILIDE.  587 

previous  small  patches  of  eryfcliema.  It  may  be  found  when  there  is 
no  other  syphilitic  eruption  upon  the  surface.  Its  appearance  is  char- 
acteristic, almost  pathognomonic  of  syphilis.  Iritis  sometimes  accom- 
panies a  severe  outbreak  of  syphilitic  papules. 

3.  General  Pustular  Syphilide.— There  are  three  varieties  of 
generalized  pustular  syphilide  belonging  to  secondary  syphilis  : 

(a)  Superficial  pustules  complicating  other  lesions. 

(b)  General  syphilitic  acne. 

(c)  Superficial  ecthyma. 

(a)  Superficial  Pustular  Sypliilide. — With  a  roseola,  or  papular 
syphilide,  or  occurring  alone,  there  may  be  some  superficial  pustules 
scattered  on  the  scalp,  or  along  the  forehead,  or  about  the  upper  lip, 
at  the  base  of  the  nose,  at  the  labial  commissures,  or,  indilfferently, 
over  any  part  of  the  body,  more  or  less  thickly.  The  pustules  are 
small,  superficial,  ephemeral,  without  any  hardened  or  elevated  base  ; 
•they  often  run  together  and  dry  up,  forming  scabs — brown,  rough,  un- 
even— like  those  seen  in  impetigo.  The  patches  always  tend  toward 
a  circular  arrangement.  Instead  of  drying  up  under  the  scabs,  slight 
ulceration  may  take  place,  with,  not  infrequently,  vegetation  of  the 
surface  by  the  excessive  growth  of  granular  tissue.  This  feature  is 
especially  noticeable  at  the  angles  of  the  lips,  or  around  the  base  of 
the  aliB  of  the  nose.  Indeed,  any  moist,  ulcerated  surface  may  granu- 
late, the  feature  being  an  epi-phenomenon,  and  not  essentially  a  char- 
acteristic of  syphilis.  Occasionally,  in  syphilis  about  the  labio-nasal 
furrows,  the  lips,  and  chin,  minute,  dry,  irregular,  papular  prom- 
inences occur  in  rows  and  segments  of  circles  where  there  has  been  no 
previous  moist  surface.  These  warty  excrescences  rarely  get  larger 
than  the  head  of  a  pin  ;  they  are  of  a  dead-gray  color,  sometimes  pig- 
mented. They  last  several  weeks,  then  dry  up  and  disappear  without 
leaving  any  cicatrix.  Hardy  has  described  the  eruption  as  ''syphilide 
granuleuse." 

There  is  nothing  about  the  slight  pustular  eruption  above  described 
characteristic  of  syphilis,  except  the  pigmentation  of  the  skin  in  the 
brown  areola  which  forms  about  the  scabs,  and  the  tawny,  vinous-red 
color  of  the  skin  left  after  the  fall  of  the  latter.  A  very  faint,  central 
depression  marks  the  sj^ot  of  the  pustule,  and  from  this  central  depres- 
sion the  clearing  up  of  the  pigmentation  begins,  progressing  centrifu- 
gally.  The  eruption  may  relapse,  several  crops  appearing  successiveh', 
especially  on  the  scalp. 

{V)  General  Sypliilitic  Acne. — This  eruption  occurs  scattered  over 
the  scalp,  face,  and  the  extremities,  the  lower  rather  than  the  upper, 
or  it  may  cover  the  whole  body.  Each  pustule  is  distinct,  and  out  of 
most  of  them  grows  a  hair.  They  are  not  prominent,  usually  small, 
often  but  little  larger  than  a  grain  of  millet,  occasionally  quite  large. 
Each  separate  pustule  rests  on  a  reddened  base,  which  itself  never  sup- 


5S8  SYnilLIS   OF   SKIN   AND   MUCOUS   MEMBRANES. 

pnrates,  the  pustule  being  superficial.  Each  pustule  grows  slowly,  tak- 
ing from  two  to  three  weeks  to  develop  and  break,  and  then  the  Huid 
hardens  into  a  dry  scab.  Tlie  hard  base  of  the  pustule  has  meantime 
been  getting  brown,  and  becoming  surrounded  by  a  copper-colored 
areola.  Wh&n  the  scab  falls,  the  elevation  constituting  the  base  of  the 
original  pustule  remains  as  a  papule,  with  a  faint  central  dei)ression. 
This  papule  becomes  gradually  absorbed,  leaving  a  purplish,  pigmented 
discoloration,  which  is  very  slow  to  disappear.  Sometimes  a  slight, 
superficial  ulceration  remains.  This  is  followed  by  a  minute,  round, 
white,  depressed  cicatrix,  very  ditferent  from  the  puckered  scar  of 
ordinary  acne. 

General  syphilitic  acne  rarely  appears  before  six  months  after  chan- 
cre, being  later  than  the  superficial  pustular  syphilide,  and  earlier  than 
the  superficial  ecthyma.  It  may  appear  very  early,  indeed  as  the  first 
eruption,  but  it  is  believed  to  indicate  a  bad  form  of  syphilis,  espe- 
cially if  accompanied  by  iritis. 

Svphilitic  acne  lasts  ordinarily  about  two  months,  but  this  limit 
may  be  gi'eatly  prolonged  by  successive  crops  of  eruptions. 

Diagnosis. — The  coppery  areola  distinguishes  syphilitic  acne  from 
other  varieties,  but  where  the  eruption  appears  late,  and  is  confined  to 
the  forehead,  temples,  and  face,  it  is  sometimes  hard  to  distinguish  it 
from  the  simple  acne  occurring  late  in  life  on  gouty  subjects. 

{c)  Superficial  Ecthyma. — Tliis  eruption  is  constituted  by  red- 
dened patches  upon  which  pustules  develop.  The  latter  may  be  um- 
bilicatcd,  much  resembling  variolous  pustules.  The  pustules  vary  in 
size  from  that  of  a  pea  to  (occasionally)  nearly  an  inch  in  diameter. 
They  are  round,  either  scattered  or  collected  into  groups,  in  which 
latter  case  they  may  run  together  (confluent).  The  pus  is  thick,  often 
bloody,  and  there  is  a  dark-red  areola  (afterward  coppery)  around  each 
pustule.  The  pustules  do  not  repose  on  a  hardened  base.  The  crust 
is  rough,  dark  brown,  with  a  greenish  shade,  and  underneath  it  there 
is  ulceration.  The  latter  heals  under  the  scab,  leaving  a  slight  cica- 
trix (often  pitted,  like  the  scar  of  vaccinia),  which  for  many  months 
retains  its  purple,  coppery  color,  gradually  whitening  from  the  center. 

Syphilitic  superficial  ecthyma  is  found  anywhere  on  the  body,  often 
on  the  scalp.  It  occurs  in  bad  cases  of  syphilis,  especially  where 
cachexia  comes  on  early.  It  rarely  appears  before  about  the  close  of  a 
year  from  chancre,  and  may  be  delayed  a  couple  of  years  or  more.  On 
the  other  hand,  it  occasionally  comes  on  as  the  first  eruption,  within 
some  weeks  after  chancre,  accompanied  by  early  cachexia,  not  yielding 
readily  to  treatment,  and  often  followed  by  extensive  ulcerations. 

Diagnosis. — When  febrile  symptoms  accompany  the  outbreak  of 
syphilitic  ecthyma,  as  they  sometimes  do,  and  the  pustules  are  umbili- 
cated,  the  disease  is  not  uncommonly  mistaken  for  variola — an  error 
to  be  avoided  by  a  study  of  the  history  of  the  case,  the  course  of  the 


PIGMENTARY   SYPHILIDE.  5S9 

eruption,  and  the  absence  of  other  symptoms  of  variola.  Cachectic 
ecthyma  may  be  confounded  with  the  syphilitic.  The  former  appears 
in  children  and  the  aged,  chiefly  on  the  legs,  is  more  purulent,  more 
inflammatory,  less  or  not  at  all  pigmented,  and  has  no  accompanying 
history  of  syphilis. 

The  superficial  ecthyma  of  secondary  syphilis  differs  from  the  so- 
called  ecthyma  of  tertiary  syphilis  in  that  the  latter  has  an  elevated, 
hard,  empurpled  base,  ulcerates  deeply,  leaves  a  considerable,  depressed 
scar  (not  pitted) ;  is,  in  short,  a  gummy  infiltration  of  the  skin,  ulcerat- 
ing superficially.  All  the  pustular  syphilides  have  the  common  char- 
acters of  lack  of  pain  and  itching,  and  the  presence  of  the  areola,  first 
of  vinous-red,  then  of  copper-color,  from  the  pigment. 

4.  PiGMENTAKT  Syphilide. — This  syphilide  has  been  described  by 
Hardy.*  It  appears  between  the  fourth  and  twelfth  month.  It  con- 
sists of  a  coffee-colored  pigmentation  of  the  skin,  without  elevation  of 
the  surface  and  without  desquamation.  The  size  of  the  spots  varies 
from  that  of  a  silver  five-cent  i^iece  to  a  quarter  of  a  dollar.  The  bor- 
ders of  each  spot  are  irregular,  and  many  of  the  patches  run  into  each 
other.  The  intervening  skin  seems  whiter  than  normal,  and  some- 
times actually  is  so. 

This  eruption  occurs  chiefly  at  the  sides  of  the  neck,  perhaps  ex- 
tending down  over  the  breast.  It  maybe  found  elsewhere.  Lymphatic 
patients,  with  white,  fine  skin,  chiefly  women,  are  subject  to  it,  but 
dark  skins  also  have  it. 

Diagnosis. — In  pityriasis  versicolor  there  are  desquamation,  itching, 
and  the  parasite  constituting  the  affection  may  be  readily  demonstrated 
by  the  microscope.  Freckles  are  smaller  and  more  generally  distrib- 
uted, never  confined  to  the  neck. 

Remarhs. — This  eruption  is  sometimes,  possibly  always,  simplv  a 
pigmentation  left  behind  by  a  roseola  or  other  syphilide  (Fox).f  It  is 
often  very  faint,  so  that  it  can  only  be  seen  by  viewing  the  neck  side- 
wise  with  the  light  shining  across  it.  It  is  found  in  some  patients  who 
deny  any  previous  eruption  upon  the  site  occupied  by  the  pigmentation. 
It  may  last  one  or  two  months  or  indefinitely,  and  is  entirely  uninflu- 
enced by  treatment.  It  is  rarely  detected  by  the  patient,  and  is  of  lit- 
tle importance,  except  as  an  additional  means  of  diagnosis  in  obscure 
cases,  since  it  only  occurs  on  syphilitic  patients. 

5.  Bullous  Syphilide, — A  syphilitic  pemphigus  upon  adults  has 
been  observed  in  a  few  cases  (Bassereau,  Zeiss,  Hardy,  and  Fox),  occur- 
ring among  the  secondary  symptoms,  confined  to  the  palms,  soles, 
backs  of  the  fingers,  and  bends  of  the  elbows,  and  relievable  by  mercu- 

*  "  Le9oii3  syr  la  Scrofule  et  les  Scrofulides  et  sur  la  Syphilis  et  les  Svphilidcs,"  Paris, 
1864,  p.  175. 

f  "  On  the  so-called  Pigmentary  Syphilide,"  ''  Am.  Journ.  ifed.  Sci.,"  April,  1878, 
p.  356. 


590  SYPHILIS  OF  SKIX  .VXD   ilUCOUS  MEMBRANES. 

rials  intcrnall}'.  This  eruption,  so  common  in  inherited  syphilis,  is  of 
the  utmost  rarity  in  adults. 

G.  Vesicular  Syphilide. — This  is  a  rare  form  of  syphilitic  erup- 
tion.    There  are  three  varieties  : 

{a)  Varicelloid  syphilide. 

(b)  Generalized  vesicular  .-yjihilide. 
((■)  Vesicular  syphilide  in  gruups. 

{a)  Varicelloid  SypliiUde. — This  form  comes  early  if  at  all — before 
the  sixth  month  after  chancre.  Small,  red,  perhai)s  slightly  elevated 
spots  appear  as  large  as  a  i)ea.  Upon  these  arise  one  or  more  pointed, 
round,  or  umbilicated  vesicles,  surrounded  at  their  base  by  a  dark-red 
areola  afterward  becoming  brown.  The  contents  of  the  vesicles  quickly 
become  purulent  and  dry  up  into  a  greenish-brown,  adherent  crust. 
This  scab  falls  in  about  a  fortnight,  leaving  a  purplish  discoloration, 
which  slowly  disappears.  There  are  usually  but  few  spots  of  eruption, 
scattered  over  the  face,  limbs,  and  body.  Successive  crops  of  vesicles 
may  prolong  the  eruption  for  several  months,  and  ordinarily  some  other 
early  syphilide  coexists  with  it, 

Diagnosis.  — V^'hQXi  there  is  considerable  syiihilitic  fever  there  is 
danger  of  confounding  this  eruption  with  varioloid.  This  may  be 
avoided  by  observing  the  color  of  the  patches,  the  areola  around  them, 
the  course  of  the  affection,  and  concomitant  symptoms. 

{b)  Genercdized  Vesicular  Syphilide. — This  is  a  vesicular  eruption, 
not  very  common,  appearing  chiefly  on  the  trunk  and  extremities, 
rarely  on  the  face.  The  vesicles  are  small  and  acuminated,  scattered 
or  united  into  patches.  When  scattered,  eacli  vesicle  is  surrounded 
by  the  characteristic  areola  ;  when  in  groups,  the  surface  from  which 
they  spring  is  of  a  vinous-red,  which  coloration  extends  slightly  be- 
yond the  border  of  the  patch.  The  vesicles  behave  in  two  different 
manners.  After  remaining  a  while  translucent  they  may  dry  up,  the 
liquid  being  reabsorbed  ;  slight  desquamation  follows,  the  brown  areola 
pales,  and  no  scar  is  left :  or  the  vesicles  become  purulent,  break,  and 
little  darkish  scabs  form  (isolated  and  not  confluent  as  in  eczema) ; 
the  scabs  separate  slowly  and  the  brown  stain  disappears,  leaving  no 
scar.     The  eruption,  in  itself  slow,  is  made  more  chronic  by  relajjse. 

Diagnosis. — In  ordinary  eczema  the  vesicles  are  small,  ephemeral, 
and  break  quickly,  leaving  an  oozing  surface  or  a  confluent  scab.  The 
eruption  itches,  and  there  is  no  coppery  areola. 

(c)  Vesicular  SypliiUde  in  Groups. — The  patches  of  syphilitic 
herpes  are  situated  on  a  base  of  specific  color.  The  vesicles  are  of 
different  sizes,  from  a  grain  of  millet  to  a  pea.  They  are  arranged  in 
irregular  groups  or  describe  circles  or  segments  of  circles.  The  vesi- 
cles last  about  a  week,  and  are  succeeded  by  little  scabs  or  by  a  fine  des- 
quamation. After  these  disappear  the  color  pales,  and  no  scar  is  left. 
Successive  crops  of  eruption  are  the  rule. 


SQUAMOUS  SYrillLIDE.  591 

Diagnosis. — Color,  areola,  and  .slowness  of  development  distin^'uish 
this  eruption  from  ordinary  herpes.  'J.lie  circinate  form  does  not  pro- 
gress centrifugally,  as  do  other  forms  of  circinate  herpes. 

7.  Squamous  Syphilide. — Nearly  all  the  eruptions  of  syphilis  go 
through  a  desquamative  stage,  and  thus  a  patch  of  eruption  which  is 
essentially  papular,  tubercular,  or  pustular  may  finally  become  scaly, 
and,  remaining  so  for  a  considerable  time,  pass  for  a  squamous  syphi- 
lide. So  also  does  pityriasis  occur  in  syphilis,  as  of  the  scalp  with  early 
alopecia ;  sometimes  in  little  patches  along  the  margin  of  the  scalp 
with  the  other  syphilides  ;  again,  with  syphilitic  cachexia,  furfuraceous 
desquamation  of  the  scalp,  or  even  of  the  whole  body,  may  be  encoun- 
tered, with  a  dry,  rough  skin.  In  none  of  these  cases,  however,  can  it 
be  affirmed  that  pityriasis  is  an  essentially  syphilitic  lesion.  It  is 
rather  a  local  consequence  of  general  blood  deterioration,  and  may  be 
induced  by  many  causes  other  than  syphilis.  There  are,  however,  two 
varieties  of  essentially  scaly  syphilide  where  the  scale  is  the  j)rominent 
lesion  from  the  first.     These  are  : 

[a)  Generalized  squamous  syphilide. 

[h)  Palmar  and  plantar  squamous  syphilide. 

{a)  Generalized  Squamous  Syphilide. — This  eruption  occurs  in  two 
varieties — as  a  guttate  or  diffused  psoriasis,  and  in  the  circinate  (lep- 
rous) form.  The  characters  of  the  eruption  are  the  same  in  both. 
They  may  be  met  together  on  the  same  subject.  The  patches  vary 
from  a  split  pea  to  a  penny  in  size — or  much  larger  in  the  circinate  or 
gyrate  form — have  (as  a  rule)  the  deep  syphilitic  color,  are  but  slightly 
elevated  above  the  surface,  not  papulated.  The  scales  are  white,  very 
fine,  not  adherent,  not  imbricated  (as  m  true  psoriasis).  After  a  few 
weeks  the  scales  fall.  They  may  be  replaced  by  others,  finer  than  the 
first,  and  thus  several  desquamations  occur.  Finally,  the  color  pales 
and  the  darkened  spot  disappears,  leaving  no  cicatrix,  provided  the 
eruption  has  not  been  a  mixed  one  (tuberculo-squamous),  which  form 
does  leave  scar  from  interstitial  absorption.  The  circinate  form  starts 
as  a  circle,  or  segment  of  a  circle,  inclosing  healthy  skin,  does  not 
generally  increase  in  size,  and  lasts  from  a  few  weeks  in  the  earlier 
variety  to  some  months  in  the  later,  where  there  is  more  interstitial 
thickening  of  the  skin.  This  eruption  does  not  appear  before  six 
months  from  chancre,  and  may  come  on  after  an  interval  of  many 
years.  It  may  coexist  with  other  sj^philodermata.  Scaly  syijhilides, 
appearing  before  six  months  from  chancre,  are  usually  the  remains  of 
previous  papular  eruptions.  The  squamous  syphilide  appears  upon  the 
trunk,  the  members,  the  face,  and  along  the  forehead  at  the  edge  of 
the  hair.  It  shows  no  tendency  to  locate  at  the  elbows  and  knees,  like 
the  non-specific  form.  The  later  its  appearance  after  chancre,  the 
longer  does  it  tend  to  remain. 

Diagnosis.  — ySlhen  not  associated  with  other  specific  lesions,  the 


592  SYPEILIS   OF   SKIN   AND  MUCOUS   MEMBRANES. 

squamous  sypliilido  is  often  dinicult  to  clistin2:ni.sh  from  non-specific 
scaly  disease.  Much  light  is  thrown  upon  such  cases  by  a  study  of  the 
jirevious  history,  on  such  points  as  the  well-known  inveterate  tendency 
of  ordinary  ]isoriasis  to  relapse,  its  tendency  to  outbreak  in  the  spring 
and  fall.  Neither  eruption  itches  (usually),  and  both  have  the  same 
livid  redness  of  color  under  the  scales,  but  ordinary  psoriasis  tends  to 
cluster  about  the  elbows  and  knees,  and  upon  the  scalji ;  its  scales  are 
thick,  imbricated,  tightly  attached,  and  lying  in  several  layers,  so  that 
it  is  ditRcult  to  scrape  tlieni  all  away  and  get  down  to  the  livid  redness 
of  the  patch  beneath,  and  when  the  scales  are  all  rudely  rubbed  olf  tlio 
patch  is  very  apt  to  bleed.  Common  lepra,  where  the  scales  come  off 
in  patches,  is  usually  much  more  extensive  in  its  distribution  than  the 
syphilitic  variety,  and  often  of  indefinite  duration,  Avhich  the  syphi- 
litic is  not.  In  the  syphilitic  affection  the  scales  are  more  lamellar, 
finer,  less  adherent,  not  imbricated,  or  in  thick  layers,  while  the  dura- 
tion of  the  eruption  is  not  so  great.  Finally,  antisyphilitic  treatment 
has  a  marked  and  often  rapid  effect  in  the  one  form,  wliile  it  does  not 
modify  the  ordinary  variety. 

The  circinate  form  in  some  of  its  stages  exactly  simulates  ordinary 
ringworm,  but  the  diagnosis  may  be  made  by  the  absence  of  spores, 
and  by  watching  the  course  of  the  eruption,  which,  in  syphilis,  remains 
stationary,  while  in  ringworm  a  progressive  centrifugal  enlargement 
is  observed. 

(b)  Palmar  and  Plantar  Squamous  SijpMlide. — This  eruption  con- 
consists  of  rounded,  livid  colored  patches  on  the  palm  or  sole,  slightly 
prominent,  hard,  covered  by  adherent,  grayish  scabs.  The  patches 
may  be  isolated  or  confluent,  and  may  reach  a  large  size,  extending  up 
to  the  wrist  or  malleolus.  Deep  fissures  may  form  upon  them,  caused 
by  motion  of  the  parts.  These  may  bleed  and  occasion  enough  pain 
to  restrict  movement  of  the  fingers.  At  the  limits  of  the  patches 
there  is  usually  a  characteristic  livid  areola.  This  eruption  differs 
from  the  small  circular  depressions  of  the  palm  with  an  undermined 
circumference  of  white,  hard  epithelium,  left  by  the  papular  or  ery- 
thematous syphilide  of  the  palm,  and  already  described  (the  squamous). 
Palmar  affection  comes  on  later  in  the  course  of  the  disease,  is  often 
of  more  considerable  extent,  and  lasts  for  several  months,  sometimes 
for  several  years. 

Diagnosis. — The  diagnosis  with  ordinary  psoriasis  is  difScult,  unless 
other  concomitant  symptoms  lend  their  aid.  Ordinary  palmar  psori- 
asis is  of  a  higher  color,  and  not  so  circular  in  its  figure.  It  generally 
itches,  has  no  marked  areola,  and  is  pretty  sure  to  coincide  with  other 
patches  of  psoriasis  (perhaps  at  the  elbows  and  knees).  Scaly  patches 
confined  to  the  palm  or  sole  always  excite  a  suspicion  of  syphilis,  and 
call  for  a  profound  study  of  the  patient's  general  condition  and  history, 
A  patient  may  have  had  syphilis  and  still  have  psoriasis  later,  not  due 


GENERAL  TUBERCULAR   SYPIIILIDE.  593 

to  specific  disease,  and  no  error  is  to  be  more  carefully  guarded  against 
than  that  of  imagining  that,  because  an  individual  has  once  had  syphilis, 
all  his  subsequent  eruptions  must  necessarily  be  due  to  the  continued 
action  of  the  virus.  The  touchstone  treatment  generally  reveals  the 
fallacy  of  this  supposition  to  the  intelligent  practitioner.  Scaly 
patches,  which  continue  for  years  in  spite  of  well-directed  treatment, 
are  not  syphilitic  as  a  rule. 

Treatment. — In  the  squamous  palmar  syphilide  the  local  meas- 
ures most  effective  are.  tar,  red  oxide  of  mercury  (in  ointment),  and 
the  pure  acid  nitrate  of  mercury,  well  rubbed  in  with  a  glass  rod 
over  small  areas  at  a  time,  the  aiojolication  to  be  renewed  in  about 
ten  days. 

8.  Gefeeal  Tubercular  Syphilide. — Tubercular  eruptions  are 
well  on  the  boundary-line  of  tertiary  syphilis.  They  are  more  fre- 
quently grouped  than  discrete,  and  often  leave  cicatrices  without 
previous  ulceration.  Still,  the  eruption  does  occur  in  a  discrete, 
general  form,  and  may  be  ranked  as  a  late  secondary  or  early  tertiary 
symptom.  The  tubercle  is  a  large  papule,  involving  the  thickness  of 
the  skin.  A  subcutaneous,  gummy  tumor  is. not  a  tubercle.  Tuber- 
cular eruptions,  generalized  or  in  groups,  are  rarely  seen  early  in. 
syphilis.  A  generalized  papulo-tubercular  eruption  may  come  on  at 
four  or  five  months,  but  groups  of  tubercles  rarely  appear  before  a  year 
after  chancre,  and  they  may  come  on  at  any  indefinite  date.  Basse- 
reau  notes  a  case  at  forty  years.  The  farther  from  chancre  the  erui?- 
tion  appears,  the  more  certain  is  it  to  be  a  patch  of  tubercles  and  not 
a  general  eruption,  and  the  more  marked  in  such  a  patch  is  the  tend- 
ency to  ulceration. 

There  are  two  forms  of  this  eruption  : 

{a)  General  tubercular  syphilide. 

{h)  Tubercular  syj)hilide  in  groups. 

{a)  General  Tubercular  Syphilide. — The  lesion  in  this  eruption  is 
a  solid,  round,  oval,  pointed,  or  flattened  tumor,  about  as  large  as  a 
pea,  at  first  shining  and  of  a  deep  red,  then  of  raw-ham  or  coppery 
color.  They  are  scattered  irregularly,  or  lie  so  as  rudely  to  describe 
circles  or  segments  of  circles.  Sometimes  the  eruption  is  confluent  in 
spots,  in  which  case  the  skin  between  the  lesions  is  similarly  colored. 
After  a  time  a  superficial  scale  covers  each  tubercle ;  this  becomes 
detached,  and  then  the  little  tumor  sinks  away  without  ulceration. 
A  slight,  depressed,  and  pigmented  spot  marks  for  a  time  the  site  of 
the  lesion,  which  also  finally  disappears,  leaving  no  trace,  or  perhaps  a 
very  superficial  cicatrix  behind.  This  scar  is  the  result  of  interstitial 
absorption  of  the  substance  of  the  true  skin,  and  does  not  necessitate 
previous  ulceration. 

Diagnosis. — The  general  tubercular  syphilide  appears  over  the 
whole  body,  perhaps  more  prominently  on  the  face  and  forehead.    Its 

38 


594:  SYPHILIS  OF  SKIN  AND  MUCOUS  MEMBRANES. 

characters  arc  so  marked  that  it  is  hardly  possible  to  confound  it  with 
any  other  allection. 

Treatment  is  mixed,  with  local  mercurials. 

{h)  Tubercular  Sijphilide  in  Groups. — The  lesions  in  this  eruption 
are  usually  smaller  than  in  the  disseminated  form,  otherwise  the  same 
description  applies  to  them.  They  may  be  no  larger  than  a  grain  of 
millet,  but  they  seem  to  involve  a  considerable  thickness  of  the  true 
skin.  They  may  be  assembled  into  irregular  groups  of  rounded  con- 
tour, or  form  circles,  segments  of  circles,  figures  of  eight.  Sometimes 
each  tubercle  continues  distinct  from  its  neighbor,  or  they  may  run 
into  each  other,  forming  a  continuous  raised  welt,  inclosing  healthy 
skin,  or  a  roughened,  thickened,  livid  patch.  In  the  circinate  form 
the  first  tubercles  undergo  absorption,  and  are  replaced  by  others  cir- 
cumferentially,  causing  the  ring  to  grow  larger  centrifugally,  as  in 
ringworm,  except  that  tiic  tubercles  which  have  disappeared  usually 
leave  little,  smooth,  round  cicatrices  behind,  first  livid,  then  white. 
Patches  of  very  small  tubercles  leave  no  scar.  Groups  of  tubercles 
may  occur  anywhere,  but  the  forehead,  cheeks,  lips,  and  nose  are 
favorite  sites.  Groups  of  syphilitic  tubercles,  in  the  period  of  decline, 
become  covered  by  a  fine  desquamation,  and,  as  each  patch  lasts  a 
considerable  time  (from  a  few  weeks  to  several  years),  the  eruption 
goes  by  the  name  of  tuberculo-squamous  syphilide.  Such  patches 
show  the  tubercular  character  of  the  eruption  more  strongly  at  the 
border  where  fresh  tubercles  are  springing  up,  while  toward  the  center 
of  the  patch  many  round,  white,  smooth,  thin  cicatrices  show  where 
tubercles  had  previously  existed.  Such  patches  are  encountered 
mainly  about  the  forehead  and  nose.  This  scarring  without  ulceration 
is  caused  as  follows  :  The  syphilitic  tubercle  is  due  to  a  diffuse  hyper- 
plasia of  small  cells  in  the  substance  of  the  true  skin.  These  cells, 
which  partake  of  the  nature  of  so-called  gummy  exudation,  grow  at 
the  expense  of  the  natural  tissues,  and  cause  the  atrophy  of  more  or 
less  of  the  substance  of  the  latter,  even  while  there  is  apparently  an 
hypertrophy,  as  evidenced  by  the  little  tumor  called  a  tubercle.  When, 
however,  the  adventitious,  newly-formed  cells  go  into  atrophy,  and 
are  absorbed  during  the  progress  of  the  eruption,  then  not  only  does 
the  tubercular  prominence  disappear,  but  the  scar  left  attests  the 
atrophy  and  absorption  of  the  true  elements  of  skin-tissue  which  took 
place  during  the  deposit  of  the  morbid  material. 

This  element  is  of  diagnostic  importance.  In  only  two  erup- 
tions— the  tubercular  (non-ulcerated)  syphilide,  and  the  tubercular 
(non-ulcoratcd)  scrofulide  in  groups  (i.  e.,  tubercular  non-ulcerated 
lupus) — is  this  important  feature  observed,  and  the  mechanism  of 
the  formation  of  scar  is  the  same  in  both  eruptions.  Groups  of 
syphilitic  tubercles  may  soften  rapidly  and  ulcerate,  but  then  the 
affection  becomes  frankly  tertiary  in  type.     The  course  of  this  syph- 


ERYTHEMA.  595 

ilide  is  always  slow,  its  duration  being  extended  by  successive  crops  of 
tubercles. 

Diagnosis. — It  is  perhaps  possible  to  confound  the  circinate  form 
of  tubercular  sjphilide  with  ringworm,  but  the  greater  infiltration  of 
the  skin,  and  usual  existence  of  scars,  deeper  color,  and  absence  of 
spores,  should  protect  the  practitioner  from  error.  Patches  of  syphilitic 
tubercles  on  a  livid  base  are  very  apt  to  be  mistaken  for  non-ulcerative 
lupus.  In  this  latter  affection  the  tubercles  are  flatter,  softer,  par- 
tially translucent,  less  livid  ;  there  is  some  swelling  of  the  subcutane- 
ous cellular  tissue  ;  the  cicatrices  upon  the  patches  are  puckered, 
irregular,  often  ridged  with  flat,  tight,  adherent,  shining  portions, 
resembling  somewhat  the  cicatrix  of  a  burn,  usually  with  a  few  veins 
running  oyer  the  surface. 

Treatment  of  the  tubercular  syphilides  is  mixed,  with  locally  mer- 
curials. 

CONCOMITANT  SYMPTOMS  ON  MUCOUS  MEMBRANES. 

The  affections  of  the  mucous  membranes  found  in  secondary 
syphilis  are  four  : 

1.  Erythema.  3.  Mucous  patches. 

3.  Ulcers.  4.  Scaly  patches. 

1.  Erythema. — The  liyperremia  of  mucous  membrane  seen  in  sec- 
ondary syphilis  usually  attacks  the  fauces.  It  generally  comes  on  from 
three  to  eight  weeks  after  chancre,  and  looks  and  acts  a  good  deal  like 
the  erythema  occasioned  by  ordinary  cold.  It  often  extends  backward 
into  the  pharynx  and  upward  into  the  posterior  nares,  possibly  occa- 
sioning a  little  deafness,  especially  if  the  tonsils  become  engorged,  as 
is  not  infrequently  the  case.  The  nasal  mucous  membrane  is  some- 
times similarly  affected,  occasioning  symptoms  of  ordinary  catarrh. 
It  occasionally  extends  downward  into  the  larynx,  resulting  in  slight 
catarrhal  laryngitis,  with  hoarseness  and  some  cough,  occasionally  tem- 
porary loss  of  voice.  Diday  mentions  an  aphonia  occurring  early  in 
syphilis,  where  the  voice  is  not  visibly  affected,  except  in  the  higher 
notes  (in  singers),  which  can  not  be  sounded.  A  few  days  of  mercu- 
rial treatment  restores  the  voice.  The  lesion  is  evidently  hypergemia. 
Erythema  of  the  fauces  is  often  attended  by  oedema  of  the  submucous 
tissue.  Faucial  erythema  usually  accompanies  the  earliest  outbreak 
of  cutaneous  syphilis.  The  tendency  to  the  formation  of  ulcers  or 
mucous  patches  upon  the  erythematous  surface  is  great  ;  but,  if  these 
do  not  form,  the  diagnosis  of  the  affection  is  not  revealed  by  any  spe- 
cial characteristics  it  possesses,  unless  it  be  that  the  inflammation  is 
less  frank,  the  color  more  dusky,  and  the  complaints  of  the  p)atient 
less  urgent  than  they  would  be  from  a  similar  amount  of  hyperemia 
dependent  upon  a  cold.  The  syphilitic  erythema  is  sometimes  seen 
in  patches,  and  may  be  punctate. 


o9G  SYPHILIS  OF  SKIX   AND   MUCOUS  MEMBRANES. 

Eicord,  iu  bis  "Iconograiihie,"  gives  a  i)late  (XV)  of  an  ervthcmu 
of  the  glans  peuis  coiueiding  witli  a  cutaneous  roseola,  and  this  plie- 
nomenon,  by  no  means  common,  may  be  occasionally  observed.  Bum- 
stead  noticed  it  in  a  case  prior  to  the  detection  of  any  cutaneous 
symptom.- 

The  erythema  of  the  throat  may  resolve,  or  (more  frequently)  ulcers 
or  mucous  patches  appear. 

Treatment  is  general  and  local,  as  ah-eady  given. 

2.  Ulcers. — Ulcers  superficial  in  character,  round,  oval,  or  irregu- 
lar in  shape,  are  found  upon  the  mucous  membranes  early  iu  secondary 
syphilis.  They  are  very  frequently  encountered  in  connection  with  the 
erythema  above  described.  Their  favorite  seat  is  in  the  fauces,  upon 
the  tonsils,  on  the  half-arches,  on  the  soft  palate  and  uvula,  along  the 
sides  and  tip  of  the  tongue,  especially  if  there  be  a  rough  portion  of 
projecting  tooth  against  which  the  tongue  rubs,  on  the  inside  of  the 
cheeks,  very  often  at  the  angles  of  the  lips,  inside  the  lower  lip,  under 
the  tongue,  along  the  fra?num,  etc.  ;  in  short,  any  portion  of  the  mu- 
cous membrane  of  the  buccal  cavity  may  be  affected,  even  the  gums. 
These  little  ulcerations  are  usually  superficial  in  character  at  first ;  if 
they  become  deeper,  the  border  thickens,  grows  red  and  angry,  and  a 
dirty-white  pellicle  covers  the  lesion.  If  they  remain  superficial,  the 
mucous  membrane  seems  to  have  been  rubbed  off,  leaving  a  raw  sur- 
face, smooth,  glistening,  red  at  its  edges.  Salt,  pepper,  etc.,  on  the 
food  occasion  sometimes  a  stinging  sensation  at  the  abraded  points. 
The  surfaces  of  these  ulcerations  are  prone  to  become  aphthous,  cov- 
ered by  a  grayish-yellow  exudation.  Ulcerations  of  similar  character 
may  affect  the  nasal  and  genital  mucous  membranes  in  both  sexes, 
especially  if  the  parts  are  not  kept  perfectly  clean. 

The  superficial  ulcers  ajipear  early  and  late  during  the  whole 
course  of  secondary  syphilis.  Lack  of  cleanliness,  the  use  of  tobacco, 
imperfect  teeth,  etc.,  are  efficient  exciting  causes.  The  ulcerated  sur- 
faces sometimes  vegetate,  i.  e.,  become  covered  by  exuberant  granula- 
tions. 

Deeper  ulcers  in  secondary  syphilis  may  depend  upon  continuance 
and  extension  of  the  foregoing  varict}^,  from  continued  irritation  (a 
projecting  tooth,  use  of  tobacco) ;  or  result  from  ulceration  of  mucous 
patches.  The  favorite  seat  of  such  deeper  ulcerations  is  on  the  tonsils. 
The  whole  of  the  fauces  may  become  brawny  around  them,  dusky  in 
color,  thickened.  The  ulcers  themselves  have  raised,  sharply-cut  bor- 
ders, yellow,  unhealthy  bases,  and  bear  a  strong  resemblance  to  ordi- 
nary chancroid.  They  are  encountered  also  at  the  angles  of  the  lips, 
inside  the  cheeks,  on  the  tongue,  and  are  found  upon  the  preputial 
mucous  membrane,  and  about  the  anus,  extending  up  into  it.  They 
often  lead  to  considerable  destruction  of  tissue  in  a  slow,  chronic  way, 
eroding  the  whole  tonsil,  or  at  the  anus  destroying  tissue  and  resulting 


MUCOUS  PATCHES.  597 

ultimately  in  stricture.  This  ulcer  and  ulcerated  chancroid  arc  the 
most  frequent  causes  of  so-called  syphilitic  stricture  of  the  rectum. 

The  ulcers  above  described  belong  to  secondary  syphilis.  They 
commence  superficially  and  not  from  within,  and  are  thus  distin- 
guishable (as  well  as  in  their  march)  from  gummy  ulcerations  of  mu- 
cous membranes  belonging  to  tertiary  disease. 

The  symptoms  of  ulcerations  of  the  fauces  usually  complained  of 
are  sore-throat,  perhaps  difficulty  in  swallowing,  and  often  pain  under 
the  jaw,  caused  by  sympathetic  swelling  of  the  submaxillary  glands. 

That  erythema  and  ulceration  of  the  other  mucous  membranes, 
oesophagus,  stomach,  intestine,  bladder,  urethra,  etc.,  may  occur  in 
secondary  syphilis,  although  highly  probable,  is  not  proved.  Symp- 
toms from  these  quarters  are  uncommon.  Tertiary  ulcerations  are 
known  to  affect  these  membranes. 

Treatment  is  general  and  local,  as  already  given. 

3.  Mucous  Patches. — The  mucous  patch  is  a  lesion  peculiar  to 
syphilis.  It  is  a  round,  oval,  or  oblong,  pale  or  rosy,  moist  spot, 
usually  elevated  above  the  integument,  sometimes  flat  or  even  de- 
pressed. The  surface  is  slightly,  sometimes  heavily,  furred,  especially 
in  the  mouth.  This  lesion  occurs  plentifully  about  all  the  mucous 
orifices,  especially  around  the  anus,  throat,  mouth,  and  in  the  pre- 
putial cul-de-sac.  It  may  develop  upon  the  site  of  an  existing  chancre, 
converting  the  latter  into  a  mucous  patch.  The  true  skin  may  also  be 
covered  by  mucous  patches,  chiefly  in  regions  where  two  surfaces  of 
skin  lie  in  contact,  especially  if  they  are  also  habitually  moist — under 
the  female  breast,  on  the  scrotum  or  upper  part  of  the  thigh,  between 
the  toes,  at  the  umbilicus.  They  are  seen  also  at  the  edges  of  the 
nails.  The  soft  skin  of  babies  is  peculiarly  subject  to  mucous  patches. 
Mucous  patches  vary  in  size  from  the  head  of  a  large  pin  to  that  of  a 
penny,  or  become  larger  if  several  run  together.  When  occurring 
upon  the  skin,  they  are  occasionally  dry,  Avart-like  (condylomata), 
elevated  considerably  above  the  surface.  Sometimes  upon  the  skin 
they  scab  over.  Condylomata  are  seen  to  best  advantage  about  the 
anus,  periuseum,  and  scrotum  ;  but  even  upon  the  skin  the  whitish 
moist  pellicle,  resembling  furred  mucous  membrane,  may  cover  them. 
The  surface  of  a  mucous  patch  either  upon  the  skin  or  mucous  mem- 
brane may  granulate,  forming  a  prominent  vegetating  surface.  Mu- 
cous patches  around  the  anus  and  genitals,  especially  in  the  preputial 
cul-de-sac  (vagina  in  female),  are  very  constantly  attended  by  the  for- 
mation of  a  viscid,  badly-smelling  secretion,  which,  in  its  turn,  if  not 
removed,  irritates  the  skin,  causes  itching,  and  may  excite  a  plentiful 
outcrop  of  vegetations,  lack  of  cleanliness  being  the  immediate  cause 
of  these  latter,  which  themselves  are  accidental,  and  not  in  any  sense 
syphilitic.  Mucous  patches  subjected  to  friction,  or  left  dirty,  are 
apt  to  ulcerate.     Such  ulcerations  are  seen  about  the  anus,  extending 


598  SYPHILIS   OF   SKIN    AND   MUCOUS  MEMBRANES. 

perhaps  into  the  rectum,  along  the  sides  of  the  scrotum  from  friction, 
between  the  toes,  where  they  may  become  very  painful,  at  the  angles 
of  the  lips,  on  the  tonsils. 

The  secretion  of  mucous  patches  is  contagious,  and  when  they  are 
present  on  the  lips,  or  anywhere  within  the  buccal  cavity,  the  patient 
can  not  be  too  urgently  warned  of  the  possibility  of  spreading  the 
disease  among  members  of  his  own  family,  by  kissing  or  using  the 
same  spoon,  cup,  pipe,  etc.,  as  other  members  of  the  household.  Mu- 
cous patDhes  of  the  mouth  are  often  of  irregular  shape,  owing  to  the 
irritation  of  friction  against  the  teeth.  At  the  angles  of  the  lips,  and 
on  the  dorsum  and  sides  of  the  tongue,  they  are  often  more  or  less 
fissured.  The  whitish  pellicle  on  the  surface  is  thick  and  adherent, 
sometimes  covering  the  whole  patch,  sometimes  having  a  circinate  dis- 
tribution. The  buccal  patches  are  usually  fiat,  sometimes  slightly 
depressed.  Upon  the  tongue  they  may  vegetate,  while  extensive  ul- 
ceration upon  the  tonsils  is  not  unusual.  In  connection  with  such 
ulcerations,  the  tonsils  swell,  there  is  a  good  deal  of  inflammatory 
thickening  and  induration  around,  swallowing  may  become  painful, 
the  submaxillary  glands  enlarge. 

Since  the  use  of  the  laryngoscope,  mucous  patches  have  been  re- 
peatedly seen  within  the  larynx  and  trachea.  They  do  not  become 
large  in  these  situations,  or  secrete  much,  and  they  disappear  in  a  few 
weeks,  even  without  treatment. 

Symptoms  are  hoarseness,  perhaps  aphonia,  no  pain,  cough,  or  ex- 
pectoration. 

Mucous  patches  come  on  with  the  earliest  syphilides.  They  appear 
upon  the  skin,  usually  in  connection  with  the  papular  syphilide,  espe- 
cially the  broad,  flat  variety.  They  may  outlast  several  crops  of  differ- 
ent eruptions,  and  they  relapse  (especially  about  the  lips,  tongue,  and 
tonsils)  with  more  pertinacity  than  any  other  symptom  of  syphilis. 
They  occur  late  along  in  the  secondary  and  even  in  the  tertiary  stage 
of  the  disease,  but  become  gradually  less  and  less  prominent,  until 
finally  they  pass  over  into  the  scaly  joatch  of  mucous  membrane,  so 
closely  resembling  the  mucous  patch  in  some  of  its  features. 

Nothing  is  of  more  importance  in  the  prevention  of  mucous  patches 
than  thorough  cleanliness,  nothing  more  active  as  an  exciting  cause 
(upon  a  syphilitic  patient)  than  local  irritation,  prominently  the  use  of 
tobacco,  smoked  or  chewed  (for  the  mouth),  or  snuffed  (for  the  nose), 
the  retention  of  a  naturally  irritating  secretion  from  lack  of  cleanliness 
for  the  anus  and  genitals.  Mucous  patches  do  not  leave  cicatrices  un- 
less they  have  ulcerated  deeply.  The  tonsils  may  hypertrophy  and 
look  excoriated  in  secondary  syphilis  without  being  the  seat  of  true 
mucous  patch. 

Diagnosis. — The  only  maladies  with  which  the  mucous  joatch  can 
be  confounded  are  certain  forms  of  so-called  canker  sore,  or  aphthous 


SCALY   PATCHES.  599 

sore  mouth,  and  a  sort  of  a  ringworm-looking  herpetic  condition  of  the 
mouth  and  tongue  seen  in  neurotic  patients.  The  former  sometimes 
copies  the  mucous  patch  (the  exulceratcd  mucous  patch)  to  perfection, 
and  there  is  no  point  of  diagnostic  differentiation  that  I  can  mention. 
The  only  difference  is  that  these  spots  are,  as  a  rule,  more  subjectively 
tender  than  the  exulcerated  mucous  patch,  and  more  likely  to  occur 
singly  than  in  groups.  The  second  affection  is  often  an  inherited  one. 
The  scalded  circular  and  oval  patches  suggest  and  do  not  closely  imi- 
tate syphilis.  The  papillae  are  prominent  and  red  in  places,  pale 
in  others,  and  the  epithelium  shed  off  certain  rounded  areas.  The 
tongue  is  very  tender,  and  the  malady  likely  to  persist,  relapsing  par- 
oxysmally. 

Treatment  of  the  mucous  patch,  simple  or  ulcerated,  is  general  and 
local,  as  already  given. 

4.  Scaly  Patches. — These  patches,  sometimes  described  as  mu- 
cous patches,  and  sometimes  as  psoriasis,  resemble  mucous  patches  to 
casual  inspection,  but  are  found  on  closer  observation  to  differ.  They 
appear  on  the  inside  of  the  cheeks,  especially  near  the  angles  of  the 
mouth,  and  on  the  sides,  tip,  and  dorsum  of  the  tongue.  They  are 
rounded  or  irregular  in  shape,  often  gyrate  on  the  back  of  the  tongue. 
They  are  flat,  smooth,  shining,  and  of  the  bluish-white  color  of  skimmed 
(city)  milk.  When  mild,  they  are  not  at  all  sensitive  ;  when  severe, 
they  become  whiter  in  color,  and  the  epithelium,  whose  thickening 
constitutes  the  lesions,  cracks  in  places,  causing  pain.  The  scales  are 
very  firmly  adherent,  so  much  so  that  it  is  often  impossible  to  scrape 
them  off,  and  very  rough  handling  fails  to  provoke  bleeding.  The 
patches  may  become  confluent  and  cover  the  greater  part  of  the  dor- 
sum of  the  tongue,  making  it  feel  stiff  and  uncomfortable  for  the 
patient. 

These  patches  sometimes  occur  along  with  the  true  mucous  patch, 
but  usually  they  appear  later  in  the  course  of  the  disease.  They  may 
be  found  at  any  time,  even  during  tertiary  syphilis,  and  often  remain 
long  after  all  other  symptoms  have  disappeared.  They  are  sometimes 
seen  in  inherited  syphilis.  Smoking  is  an  efficient  exciting  cause. 
They  are  rebellious  to  internal  measures,  and  are  more  effectively 
treated  locally.    They  indicate  a  continuance  of  the  syphilitic  diathesis. 

The  diagnosis  between  these  patches  and  ordinary  non-specific  ich- 
thyosis of  the  tongue,  or  tylosis,  is  often  impossible  from  inspection, 
alone.  In  either  condition  the  mucous  membrane  on  the  inside  of  the 
cheek  may  look  as  if  it  had  been  lightly  varnished  over  with  collo- 
dion. The  tylosis,  however,  occurs  on  the  gums  at  times,  and  on  the 
soft  parts  beneath  the  tongue  and  in  the  floor  of  the  mouth,  which  is 
not  the  case,  so  far  as  my  experience  goes,  for  syphilitic  scaly  patches. 
Moreover,  the  non-specific  epithelial  thickening  is  likely  to  be  more 
pronounced  and  irregular  than  the  syphilitic  scaly  patch.     Wart-like 


600  SYPHILIS  OF  SKIN   AND  MUCOUS  MEMBRANES. 

promineuces  of  pure  white  and  great  hardness,  and  uneven'  patches  of 
peai'ly  thickening,  are  found  in  the  non-spccilic  form.  Fissures  more 
or  less  ulcerated  occur  in  both,  but  more  on  the  dorsum  in  the  non- 
specific malady,  on  the  sides  of  tiie  tongue  in  the  syphilitic  form. 
Epithelial-  degeneration  sooner  or  later  is  to  be  feared  in  the  non-spe- 
cific form,  which,  moreover,  does  not  yield  at  all  to  antisypliilitic 
treatment,  and  is  often  scarcely  modified  by  local  means.  A  test  by 
treatment  must  be  appealed  to  to  decide  the  nature  of  some  doubtful 
cases.  I  remember  one  case  which  occurred  in  a  young  man  who  had 
no  syphilis.  It  failed  to  yield  to  treatment.  Later  the  youth  acquired 
syphilis,  and  under  the  treatment  of  tlie  latter  the  tongue  became 
much  better  than  it  hud  been  before,  although  it  did  not  entirely 
clear  up. 

Treatment. — These  scaling  patches  require  internal  mixed  treat- 
ment, and  locally  iiowcrful  stimulants.  I  think  the  acid  nitrate  of 
mercury  the  best.  Tobacco  must  be  stopped.  I  know  several  old 
cases  of  syphilis  in  which  smoking  for  a  few  days  will  produce  the 
white  appearance  over  almost  the  entire  dorsum  of  the  tongue.  In 
these  gentlemen  (all  with  ancient  syphilis)  nothing  will  keep  the 
tongue  clean  except  the  cessation  of  smoking.  These  i^atchcs,  indeed, 
have  been  called  smoker's  patches  (''plaques  des  fumeurs"). 


CHAPTER  yiL 

SYPHILIS  OF  SXm  AFD  MUCOUS  MEMBRANES. 

The  Tertiary  Syphilides. — Concomitant  Symptoms  on  Mucous  Membranes. 

The  results  of  tertiary  syphilis,  as  seen  upon  the  tegumentary  ex- 
pansions, are  most  advantageously  considered  in  connection  with  the 
lesions  of  the  same  structures  encountered  in  secondary  syphilis  already 
discussed. 

Tertiary  is  a  far  graver  form  of  syphilis  than  secondary.  Its  pre- 
siding genius  is  destruction,  the  tendency  of  its  lesions  is  to  softening 
and  ulceration,  and  the  medium  through  which  these  changes  are  ef- 
fected is  a  substance  known  as  gummy  material,  either  diffused  through 
the  tissues  or  collected  into  circumscribed  tumors.  This  gummy  ma- 
terial is  a  specific  neoplasm  analogous  to  tubercle,  cancer,  lupous  de- 
posit, etc.  It  is  a  hyperplasia  of  cells,  which  have  not  generally  the 
vitality  to  become  organized.  They  grow  at  the  expense  of  the  tissue 
in  which  they  are  formed,  and  after  reaching  a  certain  stage  of  devel- 
opment undergo  a  retrograde  metamorphosis,  and  either  become  ab- 
sorbed gradually,  without  solution  of  continuity  of  the  tissue  in  which 


TERTIARY   SYPHILITIC   CACHEXIA.  601 

they  are  deposited,  or  break  down  in  mass,  occasioning  abscess  or  ul- 
ceration— in  either  case  leaving  indelible  cicatrices  behind.  Certain 
of  the  new  formations  due  to  tertiary  syphilis  become  organized,  lead- 
ing to  permanent  thickening,  sub-periosteal  exostoses,  pachymeningi- 
tis, chronic  laryngeal  thickenings,  etc. 

Tertiary  symptoms  rarely  appear  during  the  first  two  years  after 
chancre.  After  that  period  they  may  come  on  at  any  indefinite  time, 
having  been  observed  as  late  as  fifty-five  years.  The  appearance  of 
tertiary  phenomena  (unlike  the  secondary)  is  rarely  marked  by  the 
occurrence  of  any  preparatory  or  accompanying  febrile  excitement. 
Cachexia  is  apt  to  accompany  them,  but  even  this  is  often  lacking, 
and,  except  for  the  visible  lesion  upon  the  skin,  the  patient  may  con- 
sider himself  in  perfect  health.  Tertiary  lesions  of  the  skin  and  mu- 
cous membranes  are  rarely  attended  by  any  considerable  heat,  burning, 
itching,  or  pain — in  fact,  are  usually  devoid  of  any  sensitiveness  what- 
ever. The  course  of  tertiary  affections  is  generally  slow,  occasionally 
terribly  rapid.  Sometimes  they  yield  promptly  to  treatment,  some- 
times they  are  particularly  rebellious,  lasting  for  years.  As  a  rule, 
however,  skillfully -directed  and  long -continued  treatment  masters 
them,  but  it  can  not  restore  lost  parts,  or  remove  the  indelible  injuries 
sometimes  left  by  the  ravages  of  the  disease. 

Tertiary  sypliilitic  cachexia  requires  a  word  of  description.  It  oc- 
curs at  times  independently  of  any  visible  or  tangible  lesion  ;  or,  again, 
may  accompany  any  of  the  recognized  forms  of  tertiary  disease.  It  is 
probably  always  due  to  some  physical  change  (amyloid,  gummy)  in 
the  blood-making  organs  or  the  viscera,  or  to  some  nerve-change, 
rather  than  to  any  specific  poisonous  effect  of  syphilitic  virus — since 
at  this,  the  tertiary  period  of  syphilis,  the  virus  has  lost  its  transmissi- 
bility,  and  seems  to  have  worn  out  its  intensity  by  lapse  of  time,  while 
none  the  less  the  changes  it  has  instituted  upon  the  organism  continue 
in  full  force.  Syphilitic  cachexia  is  attended  by  loss  of  aiDpetite  and 
strength,  and  by  general  anaemia.  The  sufferer  becomes  mentally  de- 
pressed. He  looks  thin  and  pinched.  The  skin  is  tawny,  dry,  dirty- 
looking,  without  luster.  The  hair  thins,  the  epidermis  exfoliates  ex- 
cessively, occasioning  a  more  or  less  general  furfuraceous  desquamation. 
The  heart  and  vessels  of  the  neck  exhibit  the  aneemic  murmur,  the 
pulse  is  small  and  rapid,  and  some  anasarca  is  apt  to  be  observed. 
Sleep  is  disturbed,  and  mental  activity  lessened.  The  patient  may 
be  nervous  and  fretful,  or  very  despondent ;  occasionally  he  keejos 
cheerful. 

This  general  condition  indicates  great  depression  of  the  vital  force. 
It  sometimes  resists  treatment  effectually,  so  that  none  of  the  so-called 
specifics  are  of  any  avail.  It  calls  for  tonics  and  change  of  life  and 
air,  and,  if  not  relieved,  becomes  progressively  worse,  either  carrvlng 
off  the  jDatient  or  favoring  his  death  by  some  intercurrent  malady. 


602  SYPniLIS  OF  SKIN  AND  MUCOUS  MEMBR.VNES. 

The  existence  of  sypliilitic  cachexia  with  other  syphilitic  lesions  always 
demands  careful  hygienic  and  tonic  as  well  as  (or  perhaps  rather  than) 
specific  treatment. 

TERTIARY    SYPHILIDES. 

The  tertiary  lesions  of  the  integument  arc  : 

1.  Ecthyma.  4.  Tertiary  ulceration. 

2.  Eupia.  5.  Gummy  subcutaneous  tumor. 

3.  Pustular  syphilide  in  groups. 

With  these  occur  on  the  mucous  membranes  : 

1.  Mucous  patches.  3.  Deep  chronic  ulcers. 

2.  Scaly  patches.  4.  Destructive  gummy  ulcers. 

1.  Ecthyma. — In  tertiary  syphilitic  ecthyma  there  is  gummy  infil- 
tration of  the  true  skin.  After  a  few  days  a  pustule  appears  on  the 
top  of  the  solid  elcA'ation.  This  grows  rapidly  and  breaks,  or  is 
scratched  off.  The  matter  dries  up  into  a  dark-brown  scab,  perhaps 
containing  a  shade  of  green.  Underneath  this  pus  forms,  increasing 
the  thickness  and  roughness  of  the  scab,  while  the  solid  portion  of  the 
lesion  increases  also  in  size,  and  becomes  surrounded  by  a  livid  areola. 
The  scab  growing  from  beneath  may  finally  become  larger  than  the 
ulcer,  but  the  livid  areola  and  the  interstitial  thickening  of  the  skin 
extend  usually  beyond  it.  Often  the  scab  is  depressed,  let-in,  as  it 
were,  inlaid  into  the  skin,  and  firmly  adherent  to  it.  If  removed,  an 
ulcer,  with  sharp-cut  edges  and  pultaceous  floor,  is  found,  very  closely 
resembling  a  chancroid. 

This  form  of  deep  ecthyma  may  occur  separately  or  in  groups  ;  in 
the  latter  case  giving  rise  to  a  scabbed  patch  of  irregular  form,  under 
which  there  is  ulceration,  which  may  become  circumscribed  and  heal 
under  the  crust,  or,  rarely,  advance  as  a  serpiginous  ulcer. 

The  favorite  seat  of  this  eruption  is  the  lower  extremities.  It  may 
occur  anywhere  upon  the  body.  The  duration  is  often  many  months, 
by  successive  crops  of  ecthymatous  pustules.  An  indelible,  oft-en 
deeply-depressed  scar  results,  which  remains  of  a  livid  color  long  after 
the  fall  of  the  scab,  and  is  bronzed  more  or  less  in  different  subjects. 
Blanching  commences  centrally,  until  finally  the  cicatrix  is  of  a  jiearly 
white,  perhaps  surrounded  by  a  faint  ring  of  pigment,  which  is  slower 
in  disappearing. 

Mixed  treatment  is  the  most  valuable. 

2.  KupiA. — The  lesion  in  rupia  is  a  bulla,  quickly  becoming  pustu- 
lar, the  pus  usually  mixed  with  blood.  It  may  be  a  flat  pustule.  It 
varies  from  the  size  of  a  pea  up  to  (in  bad  cases  )  a  penny.  It  rests 
usually  upon  a  flat  base  surrounded  by  a  red  areola.  The  pustule 
breaks  in  a  few  days  or  dries  into  a  crust,  under  which  ulceration  pro- 
gresses.    New  supplies  of  pus  are  furnished  from  beneath,  while  the 


PUSTULAR   SYPIIILIDE   IN   GROUPS.  G03 

ulceration  progresses  slowly  at  its  circumference.  Tlius  the  first  crust 
becomes  lifted  up  by  the  formation  of  a  slightly  broader  layer  of  scab 
beneath,  and,  this  process  going  on  for  weeks  or  montlis,  finally  a 
prominent,  rough,  oyster-shell-like  scab  results,  marked  by  concentric 
layers  of  a  blackish-brown  color,  often  shaded  with  green.  A  new 
bullous  ring  may  form  outside  the  crust,  and,  in  drying,  rapidly  in- 
crease the  size  of  the  latter. 

These  scabs  may  grow  to  over  an  inch  in  height  and  reach  enor- 
mous lateral  dimensions,  especially  if  the  ulcerations  under  several 
bullae  have  become  confluent.  Pressing  upon  the  crusts  will  usually 
cause  pus  to  ooze  out  from  the  side.  The  scabs  may  remain  on  until 
cicatrization  has  occurred,  and  then,  falling,  leave  a  purple,  depressed, 
slightly  irregular  spot,  which  behaves  like  the  sj)ot  left  by  deep  ecthy- 
ma, finally  becoming  white.  On  the  other  hand,  the  scabs  sometimes 
become  detached,  leaving  an  indolent  ulcer  with  sharp-cut  borders  of 
chancroid-like  aspect,  and  tending  to  extend  superficially  but  not  in 
depth. 

Eupia  is  found  upon  all  |)ortions  of  the  body,  scattered  or  in  groups, 
and  may  coexist  with  other  tertiary  or  late  secondary  lesions  (patches 
of  tubercles,  scaly  patches).  It  is  believed  to  indicate  a  bad  general 
condition. 

Treatment  is  mixed,  combined  with  a  large  share  of  tonics  and 
hygiene. 

3.  Pustular  Stphilide  in"  Groups. — In  this  affection  a  red  spot 
first  appears.  Upon  this  a  groujD  of  small  pustules  develops.  These 
become  confluent  and  break,  their  secretion  drying  up  into  a  thick, 
greenish  crust.  Outside  of  this  the  purple  color  forms  an  areola,  as  in 
the  other  varieties  of  syphilitic  ulcer  covered  by  a  scab.  The  ulcer 
extends  slowly  and  the  scab  keeps  pace  with  it  or  falls  off  in  part,  show- 
ing a  granular  (perhaps  fungous),  unhealthy  ulcer  beneath,  secreting 
a  sanious,  plastic  pus,  which  readily  reconcretes  into  scab.  The  scab 
so  formed  is  broken  up,  granular,  cracked,  and  not  prominent  as  in 
rupia.  New  pustules  at  the  circumference  slowly  tend  to  increase  the 
size  of  the  patch.  After  a  time  it  becomes  limited,  the  scab  contracts 
and  dries  up,  the  areola  becomes  more  bronzed  ;  finally  the  scab  falls, 
leaving  the  characteristic  scar,  which  whitens  very  slowly,  especially 
on  the  lower  extremities.  Instead  of  healing  under  the  scab,  the  ulcer 
may  become  serpiginous,  extending  superficially  but  not  in  depth. 

These  patches  occur  singly  or  several  at  a  time  upon  any  part  of 
the  body,  but  preferably  upon  the  face,  scalp,  neck,  and  breast. 

Diagnosis. — The  pustular  syphilide  in  groups  is  liable  to  be  con- 
founded with  the  pustular  scrofulide  in  groups,  both  having  the  same 
general  character.  The  scab  of  the  latter,  however,  is  black  or  light 
colored,  not  greenish  ;  the  borders  of  the  ulcer  are  irregular,  fringed, 
undermined ;  in  the  syphilide,  smooth,  sharp-cut,  abrupt,  adherent. 


G04  svrniLis  of  skix  and  mucous  membranes. 

The  cliaucroidal  aspect  of  the  base  and  the  cojipery  areohi  are  only 
marked  in  the  syphilitic  affection.  The  color  of  the  scrofulide  is 
l^aler.  The  cicatrix  of  the  sypbilide  is  smooth,  depressed,  thin,  violet ; 
at  first  bronzed,  then  white ;  of  the  scrofulide,  irregular,  prominent 
in  parts,  pevhaps  puckered,  adherent ;  violet  at  first,  then  pinkish 
white. 

Treatment  is  mixed,  with  iodide  in  excess. 

4.  Tertiary  Ulcerations.— The  syphilitic  ulcer  appears  in  two 
varieties  : 

{a)  Superficial  ulceration,  stationary  or  serpiginous. 

(b)  Deep,  destructive  ulceration. 

Probably  all  ulcers  encountered  in  syphilis,  even  in  the  very  super- 
ficial forms  seen  in  secondary  syphilis,  are  due  to  the  softening  of  the 
so-called  gummy  exudation,  since  this  exudation  is  nothing  more  than 
aborted  connective  tissue — connective  tissue  gone  astray  under  the 
influence  of  the  syphilitic  poison.  In  fact,  all  the  lesions  of  syphilis, 
external  or  internal  (except  the  purely  congestive),  are  dependent  ujion 
this  cell  hyperplasia  ;  but  the  longer  after  chancre  it  occurs,  the  more 
prone  it  is  to  collect  in  considerable  masses,  to  form  rapidly,  and  to 
soften  and  disintegrate  promjitly,  thus  breaking  down  into  ulceration 
and  sweeping  away  any  tissues  in  which  it  may  happen  to  have  been 
deposited.  This  considerable  collection  of  new-formed,  lowly-vitalized 
ccll-hyperplasia,  infiltrated  through  the  structures  of  the  true  skin  or 
involving  the  subcutaneous  tissues  as  well,  is  always  the  precursor  of 
syphilitic  tertiary  ulceration. 

{a)  Suj)C)'Jicial  Ulceration,  Stationary  or  Serpiginous. — This  form 
of  ulcer  may  commence  as  rupia,  ecthyma,  or  a  crop  of  pustules,  the 
ulceration,  naturally  occurring  under  the  scabs  of  these  lesions,  in- 
stead of  healing  slowly,  either  shedding  the  crust  and  remaining  indo- 
lent and  superficial,  or  progressing  in  a  serpiginous  manner.  Often, 
however,  the  precursory  lesion  is  the  tubercle  ;  a  group  of  which,  hard, 
shining,  livid,  indolent,  varying  in  size  from  a  small  pea  to  a  small  nut, 
after  remaining  a  while  stationary,  soften,  inflame,  and  ulcerate. 

This  ulceration  has  the  syphilitic  characters — sharp-cut,  prominent, 
hard,  adherent  borders,  a  smooth,  indolent,  false-membranous  bottom. 
There  is  habitually  no  pain.  An  ulcer  so  instituted  may  remain  long 
stationary,  but  usually  gradually  becomes  serpiginous,  i.  e.,  creeps  over 
the  surface.  The  advance  may  be  centrifugal  in  all  directions,  or  along 
a  narrow  track  in  curves,  inclosing  healthy  portions  of  skin  ;  or,  what 
is  most  common,  advance  may  take  place  in  one  direction,  while  the 
opposite  edge  of  the  ulcer  is  cicatrizing.  Unless  kept  off  by  dressings, 
such  ulcers  are  constantly  more  or  less  entirely  covered  up  by  thick, 
uneven,  greenish  scabs. 

The  process  of  repair  announces  itself  by  a  limitation  of  the  ulcer, 
a  flattening  of  its  sharp  borders  ;  the  base  becomes  red  and  granular, 


DEEP  ULCERATIVE  SYPHILIDE.  C05 

approaching  the  appearance  of  a  healthy  ulcer,  and  cicatrization  goes 
on,  the  scar  passing  through  the  usual  transformations  of  the  syphi- 
litic cicatrix.  This  scar  may  he  somewhat  uneven,  owing  to  the  dif- 
ferent depths  to  which  the  ulcer  has  penetrated  at  different  points. 
Several  patches  of  superficial  ulceration  not  infrequently  coexist  upon 
the  same  individual,  usually  in  dilferent  stages,  while  cicatrices — some 
white,  some  bronzed,  some  purple — show  that  the, disease  is  already 
of  long  standing. 

Treatment  is  very. effective,  usually,  in  this  form  of  ulcer,  which  is 
not  necessarily  attended  by  any  marked  cachexia.  Untreated,  succes- 
sive outbreaks  prolong  it  for  years.  Kelapse  is  liable  to  follow  a  treat- 
ment too  soon  interrupted.  The  favorite  seat  of  serpiginous  syphi- 
litic ulcers  is  around  the  Joints,  on  the  back,  and  on  the  face. 

Diagnosis. — Occasionally  the  serpiginous  ulcer  is  mistaken  for  old 
phagedenic  chancroid.  The  distinction  is  made  by  a  study  of  the  his- 
tory, the  position  of  the  lesion,  and,  above  all,  the  effect  of  inocula- 
tion ;  finally,  by  treatment. 

Treatment  is  mixed,  with  the  iodide  of  potassium  in  excess,  or,  if 
destruction  of  tissue  is  rapid,  iodide  of  potassium  alone,  in  rapidly- 
increasing  doses  until  progress  is  stayed,  and  then  by  diminishing  the 
dose  and  adding  mercury  gradually,  as  in  the  mixed  treatment. 
Locally,  after  poulticing,  iodoform  and  mercurial  jn-eparations  yield 
beneficial  results. 

{1))  Deep,  Destructive  Ulcer. — This  is  a  gummy  infiltration  of  the 
skin  appearing  in  the  tubercular  form.  It  occurs  by  preference  upon 
the  nose,  the  ear,  the  lip,  and  the  head  of  the  penis.  The  tubercle  is 
often  quite  small,  and  ulcei'ates  so  quickly  that  the  ulcers  seem  the  j^ri- 
mary  lesion ;  in  other  cases  the  tubercles  remain  some  time  before 
softening.  A  thick,  black,  rough,  greenish  crust  forms  over  the  ulcer, 
which  continues  its  ravages  beneath,  progressing  inward,  destroying 
everything  in  its  track,  including  cartilage  and  bone.  If  the  crust 
be  removed,  an  uneven  ulcer  is  revealed,  resembling  the  deeply  de- 
structive, phagedenic  chancroid  in  all  its  features.  Exposure  to  the 
air  causes  the  crust  to  reform.  During  the  whole  course  of  this  affec- 
tion there  may  be  no  constitutional  disturbance  whatever,  no  cachexia, 
and  locally  no  ajapreciable  amount  of  pain  or  discomfort.  This  form 
of  ulcer  may  last  for  years,  with  periods  of  repose  and  paroxysms  of 
progress.  It  is  not  usually  so  amenable  to  treatment  as  the  serpigi- 
nous ulcer.  The  whole  nose,  ear,  lip,  or  large  portions  of  the  penis 
may  be  eaten  away  by  it.  Its  cicatrix  behaves  like  other  sv]3hilitic 
scars,  except  that  it  is  uneven,  from  the  different  depths  to  which  ul- 
ceration has  progressed,  and  may  be  bridged  or  bridled. 

Diagnosis. — The  diagnosis  is  with  lupus  exedens,  true  cancer, 
chancroid  ;  the  former  for  the  nose,  lip,  or  ear  ;  the  two  latter  for  the 
rest  of  the  body,  especially  the  penis.     Lupus  occurs  usually  in  the 


606  SYPHILIS  OF  SKIX  AND   MUCOUS  MEMBRANES. 

yoniig,  giimmy  ulceration  in  the  old  ;  Inpns  lias  a  less  livid  border,  a 
pure  black  or  li^lit-brown  scab.  The  histor\'  throws  much  light  on 
the  subject,  and  above  all  things  concomitant  lesions,  exostoses,  optic 
neuritis  with  mydriasis,  gummy  ulceration  of  the  palate  or  pharynx. 
Finally,  the  effect  of  treatment  is  to  be  invoked.  This  form  of  disease, 
occurring  with  inherited  syphilis,  is  almost  invariably  mistaken  for 
lupus  cxedens,  and  treated  as  such. 

Epithelioma  commences  as  a  tubercle  or  a  wart,  which  remains  a 
long  time  before  beginning  to  ulcerate  ;  the  borders  of  the  ulcer  are 
everted,  knobbed,  irregular  ;  the  floor  is  more  uneven,  the  fetor 
greater,  and  the  neighboring  glands  become  involved,  which  very 
rarely  occurs  with  the  other  ulcers  under  consideration,  except  chan- 
croid. 

Especially  on  the  glans  penis  is  tertiary,  destructive  ulceration 
liable  to  be  mistaken  for  phagedenic  chancroid,  and  ineffectively 
treated.  There  is  absolutely  no  feature  among  the  physical  charac- 
ters of  the  two  ulcers  which  distinguishes  them.  Chancroid  com- 
mences by  a  pustule,  syphilitic  ulceration  does  not :  but  this  can  rarely 
be  verified.  There  is  perhaps  something  distinguishing  in  the  appear- 
ance of  the  ulcers,  which  appeals  to  the  practiced  eye,  but  it  can  not 
be  described  in  writing.  Inoculation  is  an  infallible  test,  the  history 
of  the  case  is  of  vast  importance,  the  effect  of  treatment  often  abso- 
lutely diagnostic.  Cauterization  is  rarely  more  than  temporarily  bene- 
ficial. 

Treatment  is  that  of  late  syphilis.  Local  applications  are  not  very 
serviceable. 

5.  Gummy  Tumor  of  the  Subcutaxeous  Tissue. — Gummy 
tumor  may  develop  wherever  connective  tissue  is  found,  consequently 
it  abounds  in  and  under  the  skin.  In  the  thickness  of  the  latter  it 
forms  a  tubercle,  under  the  skin  a  tumor.  In  rare  instances,  gummy 
deposit  in  the  subcutaneous  tissue  occurs  as  an  infiltration  instead  of 
in  its  usual  circumscribed  form.  The  skin  becomes  raised,  thickened, 
reddened  ;  there  are  little  ]n-omincnces  upon  it  which  ulcerate  and 
then  comport  themselves  like  the  syphilitic  ulcer.  Laucereaux  has 
well  described  this  infiltration,  and  refers  to  Vidal  de  Cassis. 

Gummy  tumors  appear  first  as  little  hard  subcutaneous  lumps, 
freely  movable  over  the  subjacent  tissues,  the  integument  slightly 
movable  over  them.  They  are  not  sensitive  to  pressure.  As  the 
tumors  slowly  increase  in  size  (they  sometimes  remain  stationary  for 
months),  the  skin  over  them  becomes  involved,  and  the  tumors 
attached  to  the  underlying  tissues  so  that  they  cease  to  be  movable. 
Now  a  purplish  discoloration  of  the  skin  commences  ;  the  tumor, 
previously  hard  and  painless,  becomes  somewhat  sensitive,  and  softens 
centrally,  the  skin  breaks  down,  and  a  thick,  puriform  material,  not 
pus,  often  mixed  with  blood,  is  discharged.     After  discharging,  the 


LESIONS  OF  MUCOUS  MEMBRANES  IN  LATE  SYPHILIS.  GOT 

lesion  remains  as  a  characteristic,  deep,  indolent,  syphilitic  ulcer, 
whose  edges  at  first  are  undermined,  remaining  stationary  or  progress- 
ing, and  in  some  cases  strongly  resembling  cancerous  ulcers,  or,  finally, 
tending  to  scab  over  and  healing  with  the  characteristic  scar. 

Gummy  tumor  often  forms  under  the  periosteum  of  superficial 
bones  (clavicle,  skull,  tibia,  ulna),  grows  quickly,  and  may  ulcerate, 
and  behave  like  the  corresponding  lesion,  subcutaneously  situated,  the 
differences  being  :  that  it  is  deeply  attached  from  the  first ;  that  bone 
may  be  felt  through  the  ulcer,  and  that  a  superficial  scale  of  bone  may 
become  necrosed,  thus  complicating  and  prolonging  the  case  (carious 
ulcer).  Subcutaneous  or  subperiosteal  gummy  tumor,  instead  of 
coming  quickly  to  the  surface,  may  diffuse  itself  laterally  after  soften- 
ing, and  occasionally  burrow  a  short  distance  before  opening. 

Subcutaneous  gummy  tumor  may  be  single  or  multiple.  The  most 
frequent  seat  is  on  the  buttocks,  neck,  head,  and  extremities.  They 
rarely  reach  a  size  larger  than  a  nut,  but  may  become  as  large  as  or 
larger  than  an  egg,  after  softening.  Their  structure,  here  as  else- 
where, is  small  rounded  cells,  more  or  less  gelatinous  ;  granular,  in- 
tercellular tissue,  with  a  few  fibers,  fusiform  cells,  and  small  vessels. 
The  constant  tendency  everywhere  is  to  undergo  retrograde  metamor- 
phosis, either  liquefying  and  ulcerating  out,  or  becoming  cheesy  and 
going  through  absorption  with  or  without  cretification.* 

Trecdment  is  that  of  late  syphilis,  by  the  iodide  of  potassium. 


AFFECTIONS  OF  MUCOUS   MEMBRANES  ENCOUNTERED  WITH  TER- 
TIARY SYPHILIDES. 

These  are  four  : 

1.  Mucous  patches.  3.  Deep  chronic  ulceration. 

2.  Scaly  patches.  4.  Destructive  gummy  ulceration. 
The  first  three  of  these  conditions  have  been  already  described    It 

is  only  necessary  to  add  further  that  mucous  patches  become  less  fre- 
quent and  scaly  patches  (sometimes  called  "  milk-spots  ")  more  com- 
mon as  the  distance  in  time  from  chancre  is  increased.  The  chronic 
ulcers  of  the  fauces  or  mucous  membrane  of  the  cheeks  at  or  near  the 
angle  of  the  lips,  surrounded  by  more  or  less  brawny  infiltration  of 
the  neighboring  tissues  (already  described),  are  found  in  tertiary  as 
well  as  in  late  secondary  syphilis.  They  are  similar  to  some  of  the 
serpiginous  or  stationary  chronic  cutaneous  ulcers,  and  undoubtedly 
often  depend  upon  a  moderate  amount  of  gummy  infiltration  of  the 
tissues.  A  favorite  seat  for  these  late  gummy  ulcers  is  the  posterior 
wall  of  the  pharynx,  high  up,  often  extending  into  the  posterior  nares, 

*  Gummata  sometimes  appear  out  of  time  in  early  syphilis,  malignant  or  otherwise. 
R.  W.  Taylor  has  collected  some  interesting  examples  of  precocious  gummata,  and  added 
some  personal  cases.     "  Am.  Journ.  Med.  Sci."  July,  1887. 


608  SYPHILIS  or  SKIN  ANT)  MUCOUS  MEMBRANES. 

and  encroaching  on  the  upper  surface  of  the  soft  pahite,  which  is  not 
necessarily  involved.  To  see  them  it  is  often  necessary  to  lift  up  the 
soft  palate  with  a  suitable  curved  probe,  while  the  mouth  is  widely 
opened,  or  even  to  use  an  inverted  laryngoscopic  mirror.  These  ulcers 
have  raised-  borders,  are  covered  by  a  tough,  whitish  secretion,  and  are 
often  raw-looking  in  parts.  They  are  encountered  also  on  the  mucous 
membrane  of  the  nose,  causing  a  slight  catarrhal  llow,  and  accompa- 
nied by  the  occasional  discharge  of  bloody  scabs  from  the  nose,  or 
*'  hawked  up  "  in  the  morning  while  clearing  the  throat.  When  the 
ulcers  are  extensive  (serpiginous),  they  indicate  long-standing,  inveter- 
ate disease.  Their  presence  may  occasion  i)ain  in  swallowing,  and 
perhaps  in  breathing. 

Treatment  is  general  and  local,  as  already  given. 

4.  Destructive  Gummy  Ulceratiox.* — This  form  of  ulcer  is  one 
of  the  most  serious  encountered  in  syphilis.  It  may  develop  as  a 
gummy  nodule  or  as  diffuse  infiltration  of  the  submucous  tissue,  or 
be  primarily  subperiosteal  on  the  wall  of  the  pharynx,  or  in  the  nasal 
cavit}',  or  on  the  hard  palate.  It  develops  first  as  one  or  more  deep, 
round,  hard,  insensitive  swellings,  possibly  a  diffuse  infiltration.  The 
mucous  membrane  may  be  unchanged  in  color  at  first  or  slightly  yel- 
lowish, if  the  tumors  are  superficial.  As  the  latter  grow,  the  mem- 
brane over  them  darkens  in  color,  becomes  oedcmatous,  then  softens 
and  rapidly  gives  way,  leaving  a  deep,  irregular  yellow  ulcer,  with 
distinct  loss  of  substance,  surrounded  by  a  line  of  inflammatory  red- 
ness. Such  ulcers  often  spread  with  alarming  rapidity,  perforating 
the  soft  palate  or  cutting  off  the  uvula  within  a  few  days,  even  hours. 
The  explosion  may  take  place  as  if  by  electricity,  and  twenty-four 
hours  deprive  a  patient  of  his  soft  palate.  Deglutition  is  sometimes 
painful,  sometimes  painless,  according  to  whether  or  not  the  ulcer  is 
put  upon  the  stretch  in  swallowing.  Any  subjacent  bone  becomes 
rapidly  eroded  and  necrosed,  so  that  the  progress  of  the  ulcer  may 
destroy  all  the  soft  and  portions  of  the  hard  palate,  more  or  less  of  the 
turbinated  and  ethmoid  bones,  with  the  vomer  and  portions  of  the 
posterior  bony  wall  of  the  pharynx,  leaving  a  vast  ulcerated  cavity  to 
represent  what  were  the  fauces  and  pharynx.  The  disease  may  extend 
inward  occasionally  and  affect  the  membranes  at  the  base  of  the  brain, 
giving  rise  to  epilepsy  or  other  nervous  phenomena.  The  voice  be- 
comes nasal,  food  and  drink  pass  forward  and  out  of  the  nose  in  swal- 
lowing, and  yet  with  all  this  the  patient  may  be  cheerful  and  suffer 
little,  often  absolutely  no  pain. 

The  secretion  of  these  ulcers  is  very  foul  and  has  a  peculiar  odor, 
in  itself  suggestive  if  not  pathognomonic.  Portions  of  bone  die  and 
are  discharged  from  time  to  time,  or  may  become  incased  in  new  bone 
during  the  process  of  repair.     The  dead  bone,  thus  remaining  incased, 

*  Gumma  of  the  tongue  will  be  described  later. 


DESTRUCTIVE   GUMMY   ULCERATION— TREAIjIENT.  fJ09 

acts  as  a  local  irritant,  and  keeps  up  ulceration  and  suppuration  per- 
haps long  after  treatment  lias  removed  all  progressive  disease. 

When  taken  early  these  ulcerations  yield  readily  to  energetic  treat- 
ment, later  they  may  i^rove  very  rebellious.  But  Nature  accomplishes 
wonders  when  repair  docs  take  place.  Cicatrization  binds  down  any 
portions  of  the  soft  palate  which  may  have  escaped  destruction,  and 
leaves  a  characteristic  seamed  and  distorted  condition  of  the  pharynx, 
perhaps  entailing  a  permanent  alteration  in  the  voice,  sometimes  ren- 
dering the  deglutition  of  fluids  difficult,  and  perhaps  only  leaving  a 
small  opening  to  mark  the  ^ite  of  the  uvula.  Such  a  condition  of 
throat  is  always  the  result  of  syphilis,  never  of  scrofula,  or  so  rarely 
that  practically  the  word  ''never"  is  allowable.  It  has  been  written 
that  scrofula  may  cause  these  throat-ravages  in  children,  because 
children  are  found  on  whom  a  syphilitic  history  or  parentage  can  not 
be  traced,  who  have  ulcers  and  other  evidences  of  so-called  scrofula 
and  destructive  ulceration  of  the  soft  palate,  perhaps  not  quite  so 
promptly  relievable  by  the  iodide  of  potassium  as  similar  fresh  condi- 
tions in  the  adult.  I  have  seen  several  striking  instances  of  this  faulty 
diagnosis,  and  have  effected  a  cure  with  the  iodide  treatment. 

The  treatment  of  pure  gumma,  wherever  found,  is  an  iodide  pushed 
rapidly.  Mercury  is  not  necessary,  although  it  may  be  combined  in 
small  quantity  with  the  iodide  without  bad  effect,  and  the  iodic  course 
may  be  followed  by  a  moderate  mercurial  course,  with,  I  believe,  good 
effect.  The  iodide  in  some  cases  must  be  pushed  with  a  bold  hand  to 
save  tissue  and  minimize  scar. 


CHAPTER  YIIL 

SYPHILIS  OF  THE  EYE.'' 

Lachrymal  Apparatus.— Eyelids.— Chancre,  Mucous  Patches,  Gummy  Tumors,  Ptosis.— Conjunc- 
tiva.— Sclera.— Cornea.— Iris.— Mydriasis,  Iritis,  Varieties  and  Complications,  acquired  and 
hereditary.— Prognosis.— Treatment.— Vitreous  Humor,  Hyalitis.— Crystalline  Lens,  Cataract.— 
Cyclitis.— Choroiditis,  exudative  and  atrophic— Retinitis.— Neuritis  Optica.— Paralysis  of  Mus- 
cles.—Periostitis. 

All  the  tissues  of  the  eye  and  also  its  surrounding  parts  may  be 
affected  by  syphilis.  The  disorders  thus  induced  are  usually  grave, 
are  sometimes  tedious,  and  are  prone  to  do  damage  to  vision.  They 
can  rarely  with  safety  be  left  to  take  their  own  course,  and  in  a  satis- 
factory degree  they  yield  to  suitable  and  early  treatment. 

*  Chapter  VIII  is  written  by  Prof.  Henry  D.  Noyes,  M.  D.,  at  the  request  of  the 
authors,  who  fully  indorse  the  opinions  therein  expressed.     It  appears  in  the  first  person, 
as  conveying  the  personal  experience  and  convictions  of  the  writer. 
39 


CilO  SYPHILIS   OF  TUE   EYE. 

Tlie  imprint  of  syphilis  on  the  eye  may  be  made  daring  any  period 
of  its  career.  Even  chancre  lias  been  fonnd  upon  the  superticial  parts, 
while,  during  the  secondary  and  later  stages,  a  variety  of  lesions  may 
appear.  Hereditary  syphilitic  taint  is  a  frequent  occurrence  in  the 
eye. 

To  give  due  attention  to  the  various  lesions  which  may  occur,  I 
adopt  the  anatomical  order  from  without  inward,  both  for  simjilicity 
and  completeness. 

THE  liACHRYMAL,  APPARATUS. 

A  certain  proportion  of  cases  of  stricture  of  the  lachrymo-nasal 
duct  are  occasioned  by  syphilis.  There  are  no  special  features  which 
characterize  these  cases  from  others.  Neither  can  tlie  usual  local  treat- 
ment by  probing  and  sometimes  by  the  employment  of  injections  be 
omitted.  It  is  not  necessary  to  dwell  on  this  point,  but  it  is  proper 
to  call  attention  to  the  not  very  infrequent  agency  of  syphilis  in  eti- 
ologv.  It  is  not  necessary  to  have  pronounced  disease  of  the  nasal 
bones  or  cartilage.  There  will  be  a  degree  of  thickening  of  the 
Schneiderian  membrane,  such  as  is  found  in  ordinary  nasal  catarrh, 
and  inquiry  will  bring  out  a  syphilitic  history.  There  may  be  perfora- 
tion of  the  septum  narium,  or  of  the  floor  of  the  nares,  or  caries  of  the 
turbinated  bones  testifying  to  the  tertiary  stage  of  syphilis,  and  with 
these  lesions  there  may  be  stricture  of  the  lachrymo-nasal  ducts  on 
one  or  both  sides.  When  such  conditions  exist,  full  doses  of  iodide 
of  potassium  will  be  required  to  effectuate  the  employment  of  probes. 
Neither  the  constitutional  nor  the  local  treatment  is  to  be  omitted.  I 
may  add  that  in  precisely  such  cases  as  these  the  use  of  probes  of  the 
largest  sizes,  viz.,  from  ten  to  fifteen  of  Theobald,  have  been  indis- 
pensable. To  bear  in  mind  the  importance  of  antisyphilitic  treatment 
in  cases  so  pronounced  as  just  described  would  be  quite  natural,  but, 
in  not  a  few  cases  which  resist  treatment  to  an  unexpected  degree,  the 
secret  of  failure  will  be  found  in  inattention  to  a  syphilitic  taint. 

It  has  occurred  to  me  to  see  a  case  of  gumma  in  the  skin  overlying 
the  lachrymal  sac.  The  diffused  character  of  the  tumor,  that  it  over- 
spread the  anatomical  limits  of  the  sac,  that  it  could  be  grasped  be- 
tween the  thumb  and  finger,  and  the  existence  of  a  syphilitic  history, 
established  the  diagnosis. 

THE   EYELIDS. 

Primary  chancre  has  been  noticed  both  in  adults  and  in  children. 
The  sore  presents  the  same  appearance  as  when  situated  on  the  geni- 
tals, and  its  treatment  does  not  require  any  special  remark.  If  on  the 
cutaneous  surface,  it  does  not  greatly  endanger  the  eye  ;  but,  if  on  the 


THE   EYELIDS.  611 

mucous  surface,  or,  as  has  been  seen,  on  the  caruncle,  it  becomes  a 
serious  thing.  The  accident  is,  however,  so  rare  that  it  does  not  seem 
worth  while  to  enlarge  on  the  subject. 

Mucotis  patches  occur  both  on  the  cutaneous  and  conjunctival  sur- 
faces of  the  lids.  I  have  seen  them  as  large  as  a  three-cent  piece,  but 
have  not  seen  any  more  serious  result  come  from  them  than  a  slight 
catarrhal  conjunctivitis.  Weak  astringent  washes,  as  of  alum  or  sul- 
phate of  zinc,  or  touching  them  with  a  solution  of  nitrate  of  silver, 
gr.  V  vel  X,  aquae  ad  3  j,  is  the  needful  local  treatment. 

Various  forms  of  secondary  cutaneous  eruptions  may  appear  on  the 
skin  of  the  eyelids,  and  the  eyelashes  and  brows  are  liable  to  be  lost 
when  the  hair  of  the  scalp  is  being  shed,  but  these  are  incidents  which 
only  call  for  passing  mention. 

Somewhat  more  imjDortant  is  the  fact  that  gummata  develop  in  the 
eyelids  and  adjacent  parts.  They  may  grow  to  be  as  large  as  a  hazel- 
nut. In  one  instance  under  my  notice,  such  a  tumor  appeared  in  the 
skin  over  the  lachrymal  sac,  and  months  after  the  first  tumor  had  dis- 
appeared another  occurred  upon  the  border  of  the  lower  lid.  These 
developments  belong  to  the  late  stages  of  syphilis,  the  tertiary  period. ; 
in  the  instance  above  alluded  to,  several  years  had  elapsed  since  the 
first  infection. 

A  mistake  is  not  unlikely  to  be  made  in  these  cases,  because  cystic 
tumors,  and  less  frequently  fibrous  tumors,  are  of  common  occurrence 
in  the  lids.  They,  like  gummata,  usually  grow  slowly  and  painlessly. 
But  it  is  not  always  true  that  gummata  grow  slowly  ;  they  may  attain 
considerable  size  in  two  weeks. 

The  skin  is  sometimes  thickened,  and  raised  above  the  surrounding 
level.  The  most  important  guide  in  diagnosis  is  that  the  swelling  in- 
volves all  the  tissues  where  it  is  located,  and,  as  it  were,  incorporates 
them  all  into  itself.  This,  in  connection  with  its  indolent,  painless 
character,  the  possible  discoloration  of  the  skin,  and  the  constitutional 
symptoms  and  history,  will  guard  one  against  the  error  of  attempting 
to  apply  the  knife  or  other  instruments  to  the  removal  of  these  tumors. 
Like  other  gummata,  they  melt  away  under  a  suitable  course  of  con- 
stitutional treatment. 

Drooping  of  the  upper  lid  (ptosis)  is  caused  by  affection  of  the  third 
nerve,  and  will  be  alluded  to  when  speaking  of  paralysis  of  the  motor 
nerves  of  the  eyeball. 

Co2irJU]srcTivA. — The  kinds  of  inflammation  which  syphilis  may 
cause  in  this  membrane  (meaning  the  ocular  conjunctiva)  are  :  First, 
sores  from  primary  infection  ;  second,  mucous  patches  ;  and,  third, 
gummy  growths.*  The  last  belongs  quite  as  much  to  the  subcon- 
junctival connective  tissue  as  to  the  mucous  membrane.  All  of  the 
above  lesions  are  rare.     The  most  frequent  is  an  ulceration  which  I 

*  See  case  by  J.  L.  Nemir,  "  Archives  of  Ophth.,"  vol.  xii,  p.  228. 


(U2  SYPHILIS  OF  THE  EYE. 

have  seen  coexisting  with  mncous  jiatches  in  tlie  mouth.  The  com- 
mon site  is  near  the  margin  of  the  cornea,  where  a  reddened  and  ele- 
vated spot  apjiears,  resembling  a  severe  phlyctenula.  It  rises  higher 
and  is  more  extensive  than  such  eruptions  usually  are,  and  it  soon 
presents  ulceration.  The  surface  not  only  becomes  excavated,  but 
shows  a  jelly-like,  semi-transparent  tissue  upon  the  eroded  part,  and 
this  may  spread  to  the  cornea.  The  ragged,  angry,  irritated  look  of 
such  an  elevated  ulcer,  with  the  broad  thickening  of  the  base,  and  the 
large  vessels  running  into  it,  its  encroachment  on  the  cornea,  its  slow 
recovery,  the  pain,  lachrymation,  and  photophobia  which  attend  it, 
mark  the  case  as  dependent  on  a  constitutional  vice.  The  search 
for  corroborative  symptoms  of  syphilis  will  usually  be  rewarded  by 
success. 

I  have  seen  this  lesion  oftener  in  women  than  in  men.  The  local 
remedies  are  :  Bathing  the  eye  with  lukewarm  water  for  short  periods, 
say  fifteen  minutes  four  or  six  times  daily ;  the  use  of  solution  of  sul- 
phate of  atropine,  gr.  ij  ad  3  j,  droiii:)ed  into  the  eye  three  to  six  times 
daily  ;  protection  against  strong  light  by  a  shade  or  blue  glasses,  and 
the  avoidance  of  remedies  of  an  irritating  quality.  Besides  these  local 
means,  the  constitutional  treatment  should  not  be  omitted  ;  the  only 
caution  to  be  observed  being  to  have  regard  to  the  state  of  the  general 
health,  and  if  needful  to  exhibit  tonics  as  preliminary  to,  or  in  con- 
nection with,  the  specific  remedies.  This  caution  is  not  unimportant, 
because  very  many  of  these  patients  will  be  found  to  be  in  a  feeble  or 
cachectic  condition,  and  their  diet  must  often  be  as  carefully  directed 
as  their  medication. 


THE   SCLERA. 

This  structure  is  occasionally  involved  in  syphilitic  lesions.  They 
api^ear  under  three  forms  :  First,  as  episcleritis  ;  second,  as  simple 
scleritis  ;  third,  as  gummy  scleritis.  The  first  of  these  varieties  may 
be  confounded  with  a  conjunctival  process,  and  the  distinction  is  not 
very  easily  made  because  the  subconjunctival  connective  tissue  is  com- 
mon to  both  structures.  The  second  variety  appears  as  a  patch  of 
injection  at  any  part  of  the  eyeball,  of  irregular  outline,  with  moder- 
ate injection,  and  mild  or  almost  no  subjective  symptoms,  such  as 
pain,  photophobia,  or  impaired  vision.  It  is  apt  to  be  rebellious  and 
])ersistent,  or  if  it  last  long  the  deeper  structures  are  apt  to  partici- 
pate, and  then  by  haziness  of  the  vitreous  and  changes  in  tlie  choroid 
and  retina  vision  will  suffer.  The  tliird  or  gummy  infiltration  will  be 
easily  recognized  by  signs  of  interstitial  deposit,  elevation,  and  red- 
ness ;  and  it  is  apt  to  spread  to  deeper  parts,  and  may  even  lead  to 
the  destruction  of  the  eye  and  to  enucleation.  It  is  the  most  rare  of 
the  varieties  of  syphilitic  scleritis.     Interesting  cases  have  been  re- 


THE   CORNEA.  013 

corded  by  Sturgis,*  by  Dclaficl(],f  by  Loring  and  Eno4  by  Von  Ifip- 
pel,*  by  J.  A.  Andrews,!  and  by  otbcrs. 

Treatment. — In  local  applications  it  is  proper  to  employ  atropine  to 
guard  against  pupillary  adhesions,  while,  if  there  be  decided  tenden- 
cies to  inflammation  of  the  ciliary  body,  a  solution  of  eserine  sulphate, 
gr.  ss.  ad  3  j,  may  be  used  twice  or  three  times  daily.  In  some  in- 
stances both  may  be  used — the  atropine  once  daily  and  the  eserine  twice 
daily — because  the  former  is  more  effective  than  the  latter.  Further, 
warm  fomentations  for  half  an  hour  to  an  hour  three  times  daily 
are  comforting  and  salutary.  In  constitutional  treatment  no  special 
suggestions  are  needful  beyond  what  belongs  to  the  stage  of  the  funda- 
mental disease  and  the  special  condition  of  the  patient. 


THE   CORNEA. 

In  a  preceding  paragraph  the  occurrence  of  the  ulceration  of  the 
cornea  in  mucous  j)atches  of  the  conjunctiva  has  been  alluded  to,  and 
needs  no  further  mention.  I  have  not  seen  these  ulcers  go  on  to  per- 
foration. 

Inflammation  of  the  cornea,  as  the  effect  of  hereditary  syphilis,  is 
a  very  common  disease  among  children.  It  usually  appears  between 
six  months  and  two  years  of  age,  while  it  may  remain  latent  until  the 
fifth  year,  or  be  seen  as  late  as  the  fifteenth  year.  In  one  instance  I 
have  seen  it  appear  so  late  as  the  thirtieth  year.  It  is  commonly  pre- 
ceded in  young  children  by  cutaneous  eruptions,  especially  about  the 
buttocks,  and  by  glandular  swellings.  Often  the  children  have  coryza, 
with  swollen  lips,  flattened  nasal  bones,  and  badly-formed  or  perishable 
teeth.  Mr.  Hutchinson  first  called  attention  to  the  importance  of  the 
teeth  as  a  significant  mark  ;  that  the  incisors  are  notched  or  pointed, 
or  very  small,  or  crooked,  or  decayed.  The  canines  as  well  as  incisors 
may  be  abnormal.  The  general  health  is  bad,  and  the  whole  nutrition 
perverted. 

The  disease  is  not  violent  in  its  onset.  A  slight  congestion  appears 
about  the  cornea,  a  little  opacity  w^ou  its  surface.  There  was  moder- 
ate photophobia  and  pain,  often  no  lachrymation.  When  the  disease 
has  deeply  involved  the  corneal  structure  the  subjective  symptoms  be- 
come intense,  and  are  often  most  distressing. 

The  alterations  of  tissue  consist  usually  in  opacity  and  vasculariza- 
tion. It  is  rare  that  ulceration,  except  of  the  minute  superficial  kind, 
or  suppuration,  occurs.     The  opacity,  which  at  the  beginning  is  faint, 

*  "Scleritis  Syphilitica,"  "Arch,  of  Dermatology,"  January,  IS'ZS,  p.  112. 
f  "Transactions  of  the  American  Ophthalmological  Society,"  1871. 

X  Ibid,  18*74,  p.  174. 

*  Graefes,  "  Archiv  fiir  Ophthal.,"  viii,  p.  288. 

II  "Syphilitic  Gumma  of  the  Sclera,"  "Arch,  of  Ophthalm.,"  vol.  xi,  p.  458,  1882. 


01-i  SYPHILIS   OF  THE   EYE. 

soon  spreads  over  tlie  Miiole  surface,  and  into  the  depth  of  the  cornea, 
and  becomes  more  intense.  It  even  affects  the  posterior  epithelial 
surface,  and,  because  of  its  extent,  is  commonly  called  keratitis  diffusa. 
Of  course  sioflit  is  at  once  injured,  and  may  be  reduced  to  mere  per- 
ception of  light. 

The  disease  may  penetrate  deeper  into  the  eye,  and  involve  both 
the  iris  and  choroid.  I  have  under  observation  a  boy,  now  fourteen 
years  old,  who  exhibits  the  effects  of  inflammation  both  of  cornea  and 
iris  and  ciliary  body — the  cornea  mottled  with  diffused  and  spotted 
ojiacities,  the  pupil  closed  and  adherent  to  the  lens,  the  tissue  of  the 
iris  atrophied  so  as  to  be  translucent  in  many  places,  and  the  periphery 
of  the  iris  drawn  backward  by  contraction  of  exudation  and  its  adher- 
ence to  the  ciliary  processes. 

The  duration  of  these  cases  under  skillful  treatment  is  from  one  to 
three  months,  when  taken  at  an  early  period  ;  but  the  continuance 
may  be  much  longer  if  the  disease  have  taken  a  severe  hold  before 
suitable  treatment  is  undertaken.  The  prognosis  as  to  vision  will  vary 
with  the  severity  of  the  attack,  but  in  general  it  may  be  considered 
favorable.  The  disease  may  occur  among  adults,  is  less  frequent,  and 
requires  no  special  descri])tion. 

The  method  of  treatment  must  first  have  respect  to  the  constitu- 
tional trouble.  By  this  I  mean  rigorous  attention  to  food,  exercise, 
and  bathing,  as  well  as  administration  of  mercurials.  Food  in  easily- 
digestible  form  must  be  given  in  quantity  and  frequency  which  the 
stomach  will  permit ;  milk,  beef-tea,  chopped  beef  or  mutton,  either 
roasted  or  broiled,  bread,  and  eggs,  are  to  be  the  chief  reliance,  while 
sweets  and  fibrous  vegetables  are  to  be  excluded.  The  child  should  be 
taken  out  of  doors  daily,  with  proper  j^rotection  from  the  light  by  a 
veil,  and  a  tepid  bath  should  be  given  every  other  da}'.  With  these 
hygienic  measures  the  tonic  and  specific  treatment  must  be  combined. 
It  is  often  advisable  to  give  cod-liver  oil,  sometimes  quinine,  or  the 
sirup  of  the  iodide  of  iron  ;  some  practitioners  think  iodide  of  potas- 
sium imjDortant,  but  it  has  not  seemed  so  in  my  experience  ;  while  the 
readiest  method  of  introducing  mercury  is  by  putting  the  blue  oint- 
ment upon  a  flannel  bandage  which  shall  be  swathed  around  the  abdo- 
men. The  ointment  must  be  renewed  night  and  morning,  and  the 
skin  carefully  sponged  with  warm  water  to  prevent  it  from  becoming 
irritable.  By  this  management  no  unpleasant  effects  take  place,  and 
the  influence  of  the  remedy  is  seen  in  the  gradual  improvement  of  the 
health  and  appetite.  The  treatment  of  the  eye  consists  in  fomenta- 
tion, by  compresses  wrung  out  of  hot  water,  for  a  period  of  one  hour 
or  two  hours  at  a  time,  three  times  daily.  The  compresses  must  be 
changed  as  fast  as  they  become  cool,  and  the  water  must  be  kept  as 
hot  as  the  hand  can  bear.  This  treatment  is  laborious,  but  is  unequaled 
in  efficacy  ;  sometimes  poultices  may  be  more  conveniently  used.     A 


THE   IRIS.  Q15 

solution  of  sulphate  of  atropine,  ^r.  ij  ad  ^  j,  should  be  dropped  into 
the  eye  three  or  six  times  daily. 

As  the  photophobia  and  acute  symptoms  abate,  the  duration  of  the 
fomentation  may  be  shortened,  until  witli  increasing  amendment  it 
may  be  stopped.  It  is  well  to  keep  up  the  atropine,  so  lon;j  as  any 
hyperaamia  remains.  Inunction  should  be  persisted  in  for  about  two 
months,  unless  contra-indications  forbid.  If  the  skin  become  fretted, 
some  other  part  of  the  body  may  be  chosen  for  the  ointment,  or 
hydrargyrum  cum  cretd  in  doses  of  five  grains,  administered  three 
times  daily.  The  twenty-per-cent  oleate  of  mercury  is  apt  to  irritate 
the  skin.  Usually  the  chief  specific  remedy  demanded  is  some  form 
of  mercury,  but  in  older  subjects  the  iodide  may  also  be  required. 
The  extreme  importance  of  using  specific  remedies  in  these  cases,  as 
well  as  of  guarding  them  as  above  indicated,  can  not  be  too  strongly 
insisted  upon. 

THE    IRIS. 

There  are  two  afl:ections  of  the  iris  which  result  from  syphilis — 
paralysis  of  the  sphincter  of  the  pupil,  causing  mydriasis,  and  inflam- 
mation. 

It  is  not  necessary  to  say  much  upon  mydriasis.  It  occurs  under 
two  conditions.  In  the  one  it  is  associated  with  evident  paralysis  of 
other  twigs  of  the  third  pair  of  nerves.  So  that,  besides  dilatation  of 
the  pupil,  there  may  be  ptosis  or  divergent  strabismus,  or  diplopia. 

Another  condition  in  which  mydriasis  appears  does  not  present  any 
sign  of  lesion  of  the  third  nerve,  so  far  as  other  twigs  are  concerned, 
but  appears  to  be  associated  with  obscure  changes  in  the  brain,  or  at 
the  base  of  the  skull,  which  may  not  at  the  time  declare  themselves  by 
noticeable  symptoms.  Nothing  definite  can  be  predicated  upon  this 
fact,  but  it  serves  to  awaken  expectation  of  a  coming  disaster.  It  is 
also  true  that  mydriasis  is  caused  by  irritation  in  the  upper  part  of 
the  spinal  cord,  or  of  the  cervical  sympathetic,  and  by  causes  wholly 
removed  from  syphilis.  It  is  often  seen  among  the  insane,  and  among 
those  called  merely  nervous. 

Furthermore,  it  must  be  stated  that  monocular  mydriasis,  without 
impairment  of  any  other  branches  of  the  motor  oculi,  results  from 
severe  use  of  the  eyes,  and  is  attended  by  paralysis  of  the  accommoda- 
tion. This  happens  among  miniature-painters,  engravers,  and  such 
classes  of  workers. 

While  saying  thus  much,  to  guard  against  error,  it  must  be  added 
that  monocular  mydriasis  occurs  from  syphilis,  unconnected  with  either 
diplopia  or  ptosis.  (For  detail  of  such  a  case,  see  a  paper  by  Meric,  in 
the  '-British  Medical  Journal"  for  January  8,  1872,  p.  29,  and  in  the 
same  paper  are  cases  recorded  in  which  mydriasis  was  combined  with 
ptosis,  all  other  branches  of  the  third  nerve  remaining  intact.) 


Gl(]  SYPHILIS  OF  THE  EYE. 

As  to  the  constitutional  treatment  of  syphilitic  mydriasis,  nothing 
special  need  be  said.  For  local  treatment  the  contraction  of  the  pupil 
may  always  be  temporarily  secured  by  putting  between  the  lids  a  solu- 
tion of  sulphate  of  eserine  or  of  the  muriate  of  pilocarpine.  But  the 
remedy  has  only  a  temporary  effect,  and  can  not  easily  bo  graduated  to 
answer  a  useful  purpose.  The  faradic  current  is  sometimes  used,  and 
Duchenne  says  he  has  had  success  by  putting  one  pole  on  the  sclera  and 
another  on  the  temi)le  ;  but  this  treatment  is  not  to  be  commended. 

Iritis. — The  most  frequent  alTection  of  the  iris  which  syphilis  pro- 
duces is  inJJammation.  It  lias  been  calculated  that  about  (ifty  per  cent 
of  all  cases  of  iritis  are  due  to  syphilis. 

The  attack  may  occur  within  a  few  weeks  or  months  after  the 
primary  affection,  or  it  may  come  among  the  later  phenomena  of  the 
secondary  stage.  Although  the  contrary  has  been  maintained,  there 
are  no  marks  in  the  iris  by  which  the  syphilitic  origin  of  an  inflam- 
matory attack  can  be  asserted.  In  other  words,  syi^hilitic  iritis  has 
the  same  symptoms  as  other  forms  of  the  disease. 

The  tendencies  of  syphilitic  iritis  are  especially  to  the  formation  of 
plastic  exudation,  and,  when  this  reaches  the  exuberance  of  gummy 
nodules,  it  is  very  rare  that  such  a  case  is  not  caused  by  syphilis.  On 
the  other  hand,  iritis  syjahilitica  may  exhibit  only  serous  effusion.  The 
most  frecpient  cases  are  those  in  which  a  moderate  quantity  of  plastic 
matter  is  thrown  out  upon  the  pupillary  border,  and  causes  adhesions 
between  it  and  the  crystalline  lens. 

A  brief  enumeration  of  the  symptoms  of  iritis  is  as  follows  :  The 
pupil  refuses  to  expand  when  the  light  is  obscured,  and  is  apt  to  be  of 
small  size  ;  the  iris-tissue  is  altered  in  color,  and  likewise  indistinct  in 
texture ;  the  color  of  the  pujiil  is  smoky,  and  not  jet-black  ;  perhaps 
the  pupil  is  irregular,  and  at  its  margin  may  be  seen  black  specks  of 
exudation  ;  the  effect  of  a  drop  of  a  solution  of  atropine  is  either  not  to 
cause  any  expansion  of  the  pupil,  or  to  give  it  an  irregular  form,  the 
margin  being  festooned  ;  there  is  hyperemia  of  the  sclera  and  conjunc- 
tiva, in  the  immediate  neighborhood  of  the  cornea,  whose  deptii  and 
extent  will  vary  with  the  severity  of  the  attack  ;  there  may  be  cliemo- 
sis  ;  there  is  lachrymation  ;  the  lids  do  not  oj)en  fully,  and  may  be  a 
little  swollen  ;  light  is  offensive  ;  pain  is  seated  in  the  ej'C,  but  more 
often  upon  the  forehead  and  temple,  or  at  the  vertex  and  occiput,  trac- 
ing the  course  of  the  supra-orbital  branch  of  the  fifth  nerve  ;  vision  is 
always  impaired,  and  sometimes  is  reduced  to  perception  of  light. 

In  serous  iritis,  the  aqueous  humor  will  be  very  dim,  and  so  abun- 
dant as  to  make  the  anterior  chamber  unusually  deep  by  pushing  back 
the  iris  and  lens.  There  are  cases  in  which  tlie  whole  anterior  cham- 
ber is  occupied  by  a  semi-gelatinous  substance,  as  if  a  thin  and  not 
well-clarified  jelly  had  coagulated  there.  This  mass  has  sometimes 
been  mistaken  for  a  dislocated  crystalline  lens.     It  consists  of  plastic 


COMPLICATIO.XS  OF   IRITIS.  617 

exudation  diffused  through  the  aqueous  fluid.  Its  appearance  when 
undergoing  absorption  is  striking,  because  the  lower  part  of  the  cham- 
ber will  be  murky  and  clouded,  wliilo  the  upper  part  will  be  compara- 
tively clear  and  display  the  iris  and  some  of  the  pupil. 

In  other  cases  plastic  material  exudes  in  nodules  upon  the  free  sur- 
face of  the  iris,  presenting  masses  like  mustard-seeds,  or  larger  bodies, 
located  upon  any  part  of  the  membrane,  but  more  commonly  around 
the  pupil.  Sometimes  this  substance  is  so  abundant  as  to  be  precipi- 
tated to  the  bottom  of  the  anterior  chamber  as  hypopyum.  These 
masses  are  sometimes  vascular,  and  their  color  is  always  a  reddish  yel- 
low. They  are  correctly  called  gummata,  and  have  been  extracted 
and  found  to  present  under  the  microscope  the  features  of  true  gummy 
exudation.  This  material,  it  must  be  understood,  infiltrates  the  whole 
thickness  of  the  iris,  and  its  adhesion  to  the  lens  is  consequently  dense. 

The  cause  of  impairment  or  loss  of  sight  is  found  in  the  turbidity 
of  the  aqueous  humor,  in  deposits  upon  and  proliferation  of  the  epi- 
thelium of  the  posterior  face  of  the  cornea,  and  in  the  obstruction  of 
the  pupil.  The  reason  why  the  pupil  in  the  beginning  of  iritis  is 
always  small  is,  that  the  hypersemia  and  swelling  of  the  tissue  compel 
the  iris  to  push  inward  in  the  only  direction  in  which  it  can  find  space. 
So  far  from  the  narrow  ptipil  being  due  to  contraction  of  the  sphincter 
pupillEe,  the  muscular  fibers  are  reluctant  to  act  because  of  the  sodden 
condition  of  the  tissue.  Inasmuch  as  a  large  part  of  the  iris  lies  in 
contact  normally  with  the  crystalline  lens,  adhesion  between  the  two 
surfaces  is  inevitable,  and  this  is  true  even  when  the  pupil  is  well  di- 
lated by  atropine,  as  is  illustrated  in  cases  of  serons  iritis. 

A  true  picture  of  iritis  can  not  be  presented  without  bringing  into 
view  complications  which  often  accompany  it. 

The  minute  opacities  above  alluded  to,  which  are  often  fonud  on 
the  inner  surface  of  the  cornea,  especially  on  its  lower  half,  are  in  part 
precipitations,  but  also  result  from  participation  of  the  epithelium 
of  the  membrane  of  Descemet  in  the  inflammatory  process. 

The  ciliary  body  and  choroid  are  still  more  frequently  affected. 
The  evidence  of  the  fact  is  not  easy  to  obtain  in  the  early  stages  of  the 
inflammation,  but  all  obstinate  and  persistent  cases  of  iritis  pass  over 
into  irido-choroiditis.  Especially  is  this  true  when  the  plastic  exuda- 
tion is  copious,  or  when  the  pupil  has  not  been  dilated.  In  old  cases 
the  iris  sometimes  gets  a  greenish  tint  or  a  chocolate-brown,  its  fibers 
look  atrophied,  none  of  the  normal  tracery  can  be  made  out,  but  a  blur 
overspreads  the  surface,  and  haemorrhages  are  apt  to  occur.  The 
vitreous  humor  is  hazy,  the  retina  suffers,  and  often  the  eyeball  be- 
comes soft  to  the  touch,  or  even  reduced  perceptibly  in  size.  Vision 
in  these  complicated  cases  is  extremely  bad.  The  sclerotic  hyperemia 
may  not  be  great,  but  is  persistent,  and  the  globe  is  both  painful  and 
acutely  sensitive  to  pressure.     Photophobia  is  often  extreme.     If  com- 


618  SYrniLis  of  the  eye. 

plete  jiosterior  synechia  be  tlio  result  of  iritis,  it  happens  in  course  of 
time  that  an  accuniuhition  oi"  lluid  takes  place  between  the  iris  and 
the  suspensory  ligament  of  the  lens,  which  pushes  the  periphery  of  the 
iris  forward  and  gives  it  the  shape  of  a  ring-cushion.  As  a  result  of 
this  condition,  the  globe  in  time  becomes  hard,  and  secondary  glau- 
coma with  excavation  of  the  o}itic  nerve  sets  in.  In  such  old  cases 
the  iris-tissue  may  atrophy  so  much  as  to  be  semi-transparent,  while 
its  fibers  show  like  the  warp  of  muslin  before  the  cross-threads  are 
woven  in. 

In  other  bad  cases,  the  iris  is  stuck  fast  to  the  lens-capsule  so  com- 
]iletely  as  to  exhibit  the  convex  outline  of  the  lens  and  to  preseut  at 
its  periphery  an  evident  furrow.  The  attempt  to  take  out  a  piece  of 
iris  in  these  cases  often  results  in  getting  aAvay  only  the  front  layer  of 
the  membrane,  while  its  posterior,  deeply-pigmentcd  layer,  sometimes 
erroneously  called  the  uvea,  remains  adlierent  to  the  lens,  and  frus- 
trates the  operation. 

The  formation  of  a  tough  fibrous  membrane  across  the  pupil,  and 
thickening  of  the  anterior  capsule  of  the  lens,  are  consequences  to  be 
naturally  looked  for  in  badly-treated  or  severe  cases  ;  while,  as  a  result 
of  irido-choroiditis,  cataract  not  seldom  arises. 

Iritis  may  attack  both  eyes,  either  in  succession  or  simultaneously, 
yet  is  frequently  confined  to  one  eye. 

The  description  above  given  applies  to  acquired  syphilis  in  its 
various  stages,  but  iritis  occurs  as  the  effect  of  hereditary  sy2)Mlitic 
taint. 

It  indeed  may  occur  in  utero,  as  is  shown  in  clearly-developed 
symptoms  of  irido-choroiditis  in  new-born  infants — the  pupil  cora- 
l^letely  shut  by  false  membrane,  the  eyeball  reduced  in  size,  the  color 
and  texture  of  the  iris  abnormal.  Hereditary  syphilitic  iritis  usually 
develops  in  the  early  months  or  years  of  infancy.  I  am  treating  a 
child  one  year  old,  in  whom,  after  the  disappearance  of  an  attack  of 
keratitis,  which  was  recognized  as  due  to  syphilitic  taint,  iritis  began. 
It  was  not  attended  by  great  external  hypera?mia  nor  pain,  there  was 
very  little  lachrymation,  no  swelling  of  the  lids,  and  moderate  photo- 
phobia ;  but  the  iris  was  almost  concealed  from  view  by  a  patch  of 
yellowish-white  lymph;  which  occupied  all  the  anterior  chamber,  ex- 
cept at  the  upper  outer  third.  The  aqueous  humor  was  so  turbid,  and 
the  iris  so  discolored,  as  to  look  nearly  black.  The  globe  was  hard, 
and  the  appearance  of  this  patch  at  first  suggested  a  chronic  choroido- 
iritis,  instead  of  an  acute  attack.  This  in  reality  is  a  sample  of  gummy 
exudation,  precisely  like  tliis  form  of  iritis  in  adults. 

Such  cases  are  uncommon,  but  have  been  noted  by  writers.  They 
yield  to  suitable  treatment,  but  great  injury  to  sight  usually  remains. 

The  prognosis  in  iritis  depends  on  the  amount  of  lesion  which  has 
been  inflicted  at  the  time  when  treatment  is  begun.     Firm  and  exten- 


TREATMENT   OF   IRITIS.  019 

sivG  attachments  to  the  lens,  and  implication  of  the  choroid,  prolon-;^ 
the  disease,  and  do  more  or  less  injury  to  sight.  Success  in  dilating 
the  pupil  is  speedily  followed  by  abatement  of  symptoms.  A  very 
large  proportion  of  cases  of  iritis,  under  early  and  judicious  treatment, 
make  a  recovery  in  all  respects  perfect. 

Treatment. — This  is  naturally  divided  into  local  and  constitutional, 
and  the  former  is  by  far  the  more  important.  The  first  and  indispen- 
sable object  of  local  treatment  is  to  secure  full  dilatation  of  the  pupil  : 
measures  to  control  hyperasmia  are  next  in  order ;  and,  finally,  reme- 
dies to  relieve  pain. 

Under  the  first  head  the  only  effective  substance  is  sulphate  of 
atropine.  It  has  entirely  put  aside  the  extract  of  belladonna,  and  in 
only  a  few  exceptional  cases  does  it  j)roduce  conjunctival  irritation, 
and  must  be  substituted  by  duhoisine  or  by  the  alkaloid  of  stramonium, 
viz.,  daturine.  The  strength  of  the  solution  of  sulphate  of  atropine 
usually  prescribed  is  gr.  ij  vel  iv  ad  |  j.  It  should  be  ordered  in 
such  frequent  repetitions  as  the  obstinacy  of  the  adhesions  shall  com- 
pel. Sometimes  the  instillation  of  three  drops,  three  times  daily,  will 
tear  some  or  all  of  the  adhesions  ;  frequently  the  same  quantity  must 
be  repeated  six  times  daily.  In  obstinate  cases  the  solution  may  be 
ordered  four  times  within  an  hour,  three  times  daily,  making  twelve 
applications.  When  the  pupil  fails  to  yield  to  such  solicitations,  the 
effect  of  atropine  will  often  be  enhanced  by  leeches  to  the  temple,  say 
three  to  six  at  a  time. 

When  the  pupil  begins  to  dilate,  the  inflammatory  s3'mptoms  usu- 
ally decline  ;  especially  is  this  true  of  jiain.  The  energy  with  which 
atropine  is  employed  is  the  peculiarity  of  the  naodern  treatment  of 
iritis,  and  is  the  chief  ground  of  success.  A  word  of  caution  must  be 
interposed  as  to  the  liability  of  bringing  on  symptoms  of  poisoning. 
This  effect  is  not  very  rare.  The  patient  finds  his  fauces  extremely 
dry,  and,  on  inspection,  their  surface  will  be  found  congested  and  a 
little  cedematous,  the  pulse  is  quickened,  a  mild  delirium  appears, 
and,  in. advanced  toxic  conditions,  violent  delirium  and  dangerous 
prostration  will  ensue.  All  this  results  from  absorption  of  the  atropine 
into  the  general  circulation.  Some  persons  experience  unpleasant 
effects  of  this  kind  very  easily. 

If  the  pupil  do  not  exj)and,  even  if  aided  by  the  application  of 
leeches,  I  have  sometimes  resorted  to  the  expedient  of  procuring  a 
rapid  but  mild  salivation  by  mercurial  remedies,  and  found  that,  when 
the  gums  were  touched,  the  pupil  either  yielded  to  the  mydriatic,  or 
the  inflammation  began  to  subside  without  expansion  of  the  pupil.  If 
it  should  not  be  deemed  wise  to  employ  this  treatment,  because  of  the 
feeble  state  of  the  patient's  health,  the  operation  of  iridectomy  is  some- 
times advisable.  It  is  not  fitted  to  the  early  states,  but  rather  to  the 
later  period  of  a  tedious  inflammation. 


020  SYrUILIS   OF  THE   EYE. 

The  removal  of  Lypera?mirt  often  ensues  wlicn  full  mydriasis  is  ob- 
tained ;  but,  if  this  be  not  so,  leeches  may  be  ajuilied  to  the  temjile 
near  the  hair  ;  three  to  six  may  be  used,  and  may  in  some  cases  need 
repetition.  Care  should  be  observed  not  to  be  too  free  in  depleting 
weakly  subjects,  and  leeches  must  be  regarded  as  having  only  a  sub- 
ordinate value.     A  mild  jnirgative  is  often  needful. 

Eelief  of  pain  is  important.  Hypodermic  injection  of  morphine 
may  be  needed  to  procure  sleep,  because  at  night  that  jmin  is  most 
troublesome.  ^Moderate  degrees  of  pain  are  relieved  by  instructing 
the  patient  to  rub  tlie  forehead  with  a  mixture  of  extract  of  belladonna 
and  powdered  opium  and.  mercurial  ointment.  A  more  ctHcicnt  topi- 
cal anodyne  is  the  oleate  of  morphine  (Squibb's),  applied  with  a  pencil 
and  allowed  to  dry  into  the  skin  of  the  forehead  and  temple.  The 
tincture  of  iodine  applied  with  a  brush  is  sometimes  effectual.  So, 
too,  it  is  often  a  comfort  to  heat  a  folded  napkin  and  press  it  against 
the  forehead.  Wet  compresses,  if  of  any  use,  should  at  the  onset  be 
cold,  and  in  the  latter  stages  be  lukewarm.  In  a  case  of  protracted 
iritis,  the  prolonged  use  of  slippery-elm  poultices  is  of  the  utmost 
benefit.  They  may  be  applied  for  two  hours  at  a  time,  three  times  a 
day  if  necessary.  The  eye  must  be  guarded  against  excessive  light  by 
blue  or  smoked  glasses,  although  rigorous  confinement  to  a  dark  room 
is  not  good  practice,  because  of  its  weakening  influence  on  the  health. 
It  will  be  found  that  feeble  and  cachectic  subjects  are  more  difficult 
to  cure  than  the  robust.  If  only  one  eye  is  involved,  the  patient 
should  not  use  the  other  in  any  fine  work.  Exposure  to  the  wind 
and  smoking  are  to  be  avoided,  and  no  attempt  made  to  use  the  eye 
on  near  objects. 

The  question  of  constitutional  treatment  is  important  to  be  settled. 
In  former  times  it  was  assigned  the  chief  part  in  the  cure.  By  some, 
at  the  present  day,  it  is  almost  ignored. 

I  have  seen  a  very  large  number,  and,  indeed,  the  majority,  of 
cases  of  syphilitic  iritis  recover  without  being  subjected  to  any  of  the 
so-called  specific  remedies.  As  above  remarked,  the  facility  of  cure 
depends  most  upon  the  readiness  with  which  the  pupil  expands  and 
can  be  kept  open. 

I  have  also  said  that  sometimes  the  mercurial  treatment  will  bring 
about  prompt  resolution  when  mydriatics  faik  I  must  also  say  that 
where  the  plastic  exudation  is  in  large  quantity,  as  when  the  so-called 
gummata  make  their  appearance,  mercurial  inunction,  or  blue-pill  by 
the  mouth,  may  wisely  be  employed  to  aid  in  the  disappearance  of  the 
exudation.  I  have  seen  entire  absorption  take  place  without  this  rem- 
edy, and  in  feeble  patients  would  be  unwilling  to  use  it,  but  would 
give  the  vigorous  the  benefit  of  it. 

I  have  no  hesitation  in  stating  that  the  usefulness  of  either  mer- 
cury or  iodine  to  cure  iritis  is  excei^tioual  and  not  the  rule. 


TREATMENT   OF  IRITIS.  021 

On  the  otlicr  hand,  I  must  with  equal  readiness  admit  tliat  specific 
constitutional  treatment  ought  to  be  em2)loyed  to  counteract  the  poison 
whose  potent  influence  has  induced  the  iritis.  This  treatment  is  aimed 
at  the  general  disease,  and  is  to  be  selected  and  adapted  according  to 
the  rules  which  are  set  forth  in  another  part  of  this  treatise.  Accord- 
ing to  this  view  of  the  question,  a  practitioner  is  not  compelled  to  dose 
a  syphilitic  patient  with  mercurials  to  protect  his  sight  from  the  mis- 
chiefs of  iritis,  except  under  conditions  specified,  but  should  stead- 
fastly adhere  to  that  .plan  of  treatment  which  the  general  welfare  of 
the  system  demands,  and  attack  the  eye-disease  with  the  local  reme- 
dies which  have  been  designated. 

I  have  several  times  observed  patients  with  active  iritis  in  one  eye, 
who  have  already  been  brought  under  the  influence  of  mercury, 
attacked  with  the  same  inflammation  in  the  other.  This  certainly 
proves  that  no  preventive  virtue  can  be  ascribed  to  the  mercury,  and 
argues  against  the  beneficial  influence  of  quick  mercurial ization  in 
curing  the  acute  attack. 

In  addition  to  the  above  remarks  on  treatment,  I  should  speak  of 
certain  peculiar  conditions  calling  for  special  measures.  In  cases  of 
iritis  serosa,  where  there  is  but  little  plastic  exudation,  the  pupil  will 
dilate  readily,  but  often  the  pain  and  redness  do  not  abate.  On  test- 
ing by  the  finger,  the  eye  will  be  found  tense  and  the  anterior  cham- 
ber will  be  too  deep.  Under  these  circumstances,  paracentesis  by  a 
broad  needle  or  a  Graefe's  cataract-knife  is  indicated.  It  is  not  neces- 
sary to  draw  off  all  the  aqueous  humor,  but  the  proceeding  may  need 
several  repetitions,  as  indicated  by  the  recurrence  of  pain.  The  place 
of  puncture  should  be  at  the  margin  of  the  cornea ;  the  instrument 
should  have  a  very  sharp  point,  and  be  entered  in  a  plane  jjarallel  to 
the  surface  of  the  iris.  It  should  be  withdrawn  slowly,  because  a  rapid 
gush  of  aqueous  humor  causes  severe  pain. 

If,  after  an  attack  of  iritis  has  passed  away,  the  pupil  should  be  tied 
to  the  lens  by  extensive  adhesions,  relapses  of  inflammation  are  likely 
to  occur,  and  the  morbid  process  is  prone  to  penetrate  to  the  ciliary 
body  and  choroid.  Hence  arise  opacities  in  the  vitreous  humor  and 
in  the  crystalline  lens. 

The  area  of  the  pupil  is  sometimes  occupied  by  a  false  membrane, 
and  the  capsule  of  the  lens  may  undergo  thickening. 

If  posterior  synechia  is  complete,  that  is,  if  all  the  pupillary  edge 
be  glued  to  the  lens,  an  accumulation  of  aqueous  humor  sometimes 
takes  place  behind  the  iris,  which  makes  it  bulge  forward  toward  the 
cornea  in  a  series  of  protuberances  or  as  a  complete  ring,  leaving  the 
pupil  retracted.  The  peripheral  parts  of  the  iris  sometimes  come  into 
actual  contact  with  the  posterior  surface  of  the  cornea,  and  the  tissue 
always  undergoes  atrophy.  So  great  sometimes  is  the  waste  of  the 
tissue  that  in  spots  it  becomes  a  mesh-work  of  fibers  through  which 


(322  SYPUILIS   OF   THE   EYE. 

the  light  of  the  ophthalmoscope  can  be  thrown.  This  has  already 
been  alluded  to.  On  the  other  hand,  after  iritis,  the  membraue  some- 
times becomes  greatly  tliickencd  by  formation  of  new  tissue  both  in 
its  stroma  and  on  the  posterior  surface. 

The  remedy  for  the  conditions  of  adhesion  and  obstruction  is  iridec-' 
tomy.  Its  efficacy  will,  however,  be  in  the  inverse  ratio  to  the  severity 
of  the  lesion.  In  the  worst  cases,  especially  in  those  last  described,  it 
is  sometimes  scarcely  possible  to  be  performed,  and  seldom,  if  done,  is 
of  much  service.  Where  the  iris  is  turgid  with  new  vessels  the  opera- 
tion is  attended  by  great  bleeding,  and  no  good,  but  rather  harm  to 
the  eye,  may  ensue. 

In  spite,  however,  of  these  drawbacks,  this  operation  offers  the 
only  chance  to  rescue  the  eye  from  serious  and  cumulative  mischief, 
and  may  be  the  only  means  of  avoiding  the  necessity  of  extirpating 
the  organ. 

For  cases  of  moderate  posterior  synechia  it  may  be  needless  to  do 
anvthing,  or  the  simple  pulling  away  of  the  attachments  by  a  fine  pair 
of  forceps  will  suffice.  This  proceeding  is  attended  by  only  sliglit 
reaction,  and  requires  a  small  wound  at  the  border  of  the  cornea — the 
iris  is  seized  and  pulled  ujion  until  the  adhesion  breaks,  and  is  then  let 
go,  without  being  dragged  into  the  wound.  The  forceps  employed 
should  not  have  teeth.  This  operation,  suggested  by  Passavant,  is 
preferable  to  other  methods  of  detaching  the  pupil,  such  as  that  de- 
vised by  Streatfield.  But  it  is  now  much  less  frequently  employed 
than  it  was  a  few  years  ago. 

VITREOUS    HUMOH. 

A  common  effect  of  inflammation  of  the  iris  and  ciliary  body  and 
choroid  is  the  production  of  opacities  in  the  corpus  vitreum.  They 
are  either  effusions  from  the  surrounding  vascular  tissues  or  prolifera- 
tions and  degenerations  of  the  cells  of  the  vitreous.  The  anterior  part 
of  the  mass  is  most  frequently  affected.  The  opacities  jiresent  every 
variety  of  form,  such  as  molecules,  fibers,  tangled  nets,  flakes,  and 
membranes.  They  sometimes  develop  rapidly,  more  frequently  they 
occur  slowly.  A  noteworthy  instance  of  rapid  development  is  the  fol- 
lowing :  Lieutenant  D had  hard  chancre  in  March,  1872.     In  the 

following  September,  double  iritis  took  place,  and  disappeared  in  four 
weeks,  leaving  a  few  adhesions  of  the  pupil  of  one  eye.  Vision  in  the 
right  eye  was  |§ ;  in  the  other,  |^.  In  June,  1873— about  eight 
months  afterward — a  sudden  development  of  opacities  occurred  in  the 
vitreous  of  the  left  eye,  totally  abolishing  vision,  but  leaving  percep- 
tion of  light.  No  external  hypersemia  of  the  globe  existed — the  fun- 
dus could  not  be  discerned.  The  appearance  of  the  vitreous  was  like 
that  of  a  tumbler  filled  with  muddy  water  in  whicli  a  quantity  of  torn 


VITREOUS  HUMOR,  623 

and  broken  leaves  are  floating.  He  had  been  under  mercurial  treat- 
ment, both  at  the  time  vvlicn  the  chancre  appeared  and  during  the 
attack  of  iritis  ;  in  tlic  hist  instance  it  was  maintained  for  three 
months.  When,  tlie  acute  hyalitis  appeared  he  was  directed  to  take  a 
wineglassful  of  Zittman's  decoction  three  times  daily,  and  by  a  life 
of  regulated  exercise  in  the  country  to  keep  his  general  health  in  tlie 
best  condition.  After  six  weeks  the  vitreous  became  so  clear  that  the 
fundus  could  be  perfectly  examined.  No  lesions  of  the  choroid  could 
anywhere  be  found,  and  vision  was  restored  to  |g-.  The  other  eye  was 
not  affected. 

A  case  precisely  like  the  above  is  not  often  observed,  but  a  process 
slower  in  development  and  less  in  degree  is  a  not  rare  effect  of  syphi- 
litic poison. 

It  usually  requires  a  long  time  for  vitreous  opacities  to  clear  up — 
generally  some  of  them  remain  permanently. 

The  CRYSTALLiisrE  LENS  is,  so  far  as  I  know,  never  the  seat  of 
syphilitic  changes,  excepting  as  they  ensue  in  the  course  of  inflamma- 
tions of  the  choroid,  the  ciliary  body,  or  the  iris.  More  especially  from 
chronic  cyclitis  and  choroiditis  does  the  nutrition  of  the  lens  become 
impaired  and  its  transj^arency  become  damaged.  In  other  words,  it  is 
changed  into  a  cataract.  The  transformation  of  the  lens-fibers  begins 
in  the  deeper  or  posterior  layers  very  often,  and  the  lens  when  wholly 
opaque  is  either  of  a  dead  white  or  yellow  tint,  or  becomes,  in  old 
cases,  completely  calcified.  As  a  result  of  iritis,  the  anterior  capsule 
sometimes  presents  opacities,  by  proliferation  of  the  epithelium  of  its 
posterior  surface. 

Nothing  is  gained  in  the  attemjDt  to  cure  opacities  of  the  lens  or  its 
capsule  by  antisyphilitic  medication.  The  case  will  admit  only  of 
surgical  treatment,  and  in  all  cases  the  likelihood  of  success  depends 
on  the  degree  to  which  the  integrity  of  the  deep  tissues  has  been  pre- 
served. It  is  always  imperative  to  make  a  rigid  investigation  of  the 
degree  of  perception  of  light,  and  the  limits  of  the  field  of  vision. 
Only  by  so  doing  can  a  patient  be  secured  against  the  pain  and  disap- 
pointment of  a  needless  operation. 

The  operation  for  cataract  under  these  circumstances  is  always  com- 
plicated and  may  be  quite  difScult.  For  a  discussion  of  this  subject  it 
is  proper  to  refer  to  treatises  devoted  to  diseases  of  the  eye,  while  it  is 
right  to  add  that  the  probabilities  of  success  in  this  class  of  cases  are 
not  encouraging. 

THE    CILIARY    BODY. 

I  should  not  make  special  mention  of  inflammation  of  this  part  of 
the  uveal  tract,  were  it  not  that  certain  acute  lesions  of  this  tissue 
sometimes  present  themselves  which  have  very  stiiking  features.    It  is 


624  SYPHILIS  OF  tue  eye. 

the  most  highly  vascular  structure  of  the  eye,  autl  of  necessity  partici- 
pates in  the  inllammatery  changes  of  the  iris  and  choroid.  But  it  is 
entirely  hidden  from  direct  inspection,  either  by  the  naked  eye  or  by 
the  ophthalmoscope.  I  have  before  alluded  to  a  retraction  of  the 
periphery  6t  the  iris  which  indicates  adhesion  between  it  and  the  cili- 
ary processes.  So  far  as  superficial  vessels  may  indicate  the  existence 
of  cyclitis,  the  same  kind  of  hypcra^mia  appears  as  when  the  iris  is  in- 
flamed ;  that  is,  the  anterior  ciliary  vessels  become  engorged. 

Ci/ch'tis,  as  an  independent  affection  with  unmistakable  features, 
has  appeared  to  me  under  two  forms.  In  one  there  are  no  other 
symptoms  than  circumcorneal  injection,  and  a  little  discoloration  of 
the  iris,  without  impairment  of  the  action  of  the  pupil ;  the  vision 
may  be  dim.  In  the  other  and  more  important  form,  the  inllanima- 
tiou  presents  gummy  exudation  more  or  less  conspicuous.  I  shall 
speak  only  of  the  latter  condition,  and  by  relating  the  following- 
case  : 

A  man,  about  thirty-two  3"ears  of  age,  had  had  syjDhilitic  symptoms 
about  four  years  ;  had  had  iritis.  A  few  weeks  before  I  saw  him  sud- 
den blindness  fell  upon  his  left  eye,  without  pain,  irritation,  or  visible 
redness.  lie  was  able  to  perceive  only  an  intense  light.  The  globe 
was  not  hard  or  tender  to  touch.  The  pupil  dilated  fairly  by  atro- 
pine, and  no  illumination  of  the  bottom  of  the  eye  could  be  obtained 
by  the  ophthalmoscope.  The  vitreous  simply  gave  back  an  inky  hue. 
As  the  eye  turned  in  various  directions  a  white  object  suddenly  flashed 
across  the  field,  in  most  instances  starting  from  the  inferior  part  of  the 
globe.  It  was  evidently  close  behind  the  lens,  and  never  retired  to  the 
depths  of  the  eye.  When  he  looked  strongly  downward  a  white  patch 
was  discovered  close  to  the  border  of  the  crj'stalline  lens,  situated  in 
the  ciliary  body,  or  its  near  neighborhood.  This  had  the  look  of  plas- 
tic exudation.  The  nature  of  the  disease  was  then  assumed  to  be  a 
plastic  cyclitis,  with  a  localized  exudation  not  very  abundant,  from 
which  a  mass  had  been  broken  off,  and  floated  about  in  the  anterior 
part  of  the  vitreous.  The  general  opacity  would  be  the  necessary  ac- 
companiment of  this  condition.  The  patient  had  been  treated  by  spe- 
cific remedies,  and  they  were  again  prescribed,  but,  after  a  period  of 
two  months,  no  improvement  was  obtained  in  vision,  and  the  exuda- 
tion had  scarcely  altered  its  appearance.  There  was  never  any  visi- 
ble hyperaemia  or  pain. 

In  other  cases  plastic  cyclitis  appears  in  a  much  more  formidable 
way.  In  addition  to  the  pain,  swelling  of  the  lids,  and  vascularity, 
characteristic  of  a  severe  attack  of  inflammation  of  the  globe,  a  swell- 
ing soon  begins  to  arise  at  some  portion  of  the  eye  near  the  cornea. 
The  spot  from  wllich  it  springs  may  be  more  intensely  red  than  other 
situations,  and  the  locality  where  I  have  most  often  seen  it  is  at  the 
upper  part  of  the  eyeball.     The  tumor  grows  rapidly,  and  within  a 


CYCLITIS— CHOROIDITIS.  C25 

week  I  have  seen  it  become  liirger  than  a  buck-shot,  its  base  occupying 
nearly  one  fourth  the  circuriil'erence  of  tliis  part  of  the  globe. 

There  is  always  severe  iritis,  the  pupil  is  totally  obscure  to  the 
ophthalmoscope,  and  the  anterior  chamber  filled  with  turbid  aqueous 
humor.  The  disease  occupies  several  weeks  in  its  course,  and  the  tu- 
mor will  entirely  disappear.  Sometimes  its  site  is  marked  by  a  dark- 
bluish  discoloration.  Sometimes  the  eye  becomes  soft  and  slightly 
reduced  in  size,  but  this  is  not  a  uniform  result.  In  no  instance  have 
I  seen  any  vision  restored.  It  is  not  needful  to  dwell  upon  the  subject 
of  treatment,  because  the  measures  suitable  to  a  similar  process  in  the 
iris  would  be  indicated.  In  some  cases  I  have  been  obliged  to  extirpate 
the  eye,  because  of  the  severity  of  the  pain. 

THE   CHOROIDEA. 

The  frequent  participation  of  this  membrane  in  the  inflammations 
of  the  iris  has  been  repeatedly  alluded  to,  and  need  not  be  further 
mentioned. 

The  similarity  in  structure  of  the  two  tissues  causes  a  great  resem- 
blance in  their  morbid  processes,  but  in  many  instances  it  becomes 
impossible  to  see  the  changes  which  occur  in  the  choroid,  because  the 
pupil  and  refractive  media  become  so  soon  and  so  deeply  clouded.  A 
form  of  choroiditis  which  may  take  place  without  affection  of  the  iris, 
and  without  visible  hypersemia  of  the  globe,  is  known  by  the  name  of 
acute  choroiditis  disseminata.  Illuminated  by  the  ophthalmoscoiDe, 
the  vitreous  will  be  faintly  hazy,  but  through  it  will  be  discerned  a 
number  of  small  isolated  specks  of  a  light-yellow  color  upon  the  pos- 
terior wall  of  the  eye.  These  specks  are  more  apt  to  exist  near  the 
equator,  but  may  appear  upon  the  central  part  of  the  fundus.  •  They 
are  seldom  bigger  than  one  fourth  of  the  area  of  the  optic  nerve,  often 
are  much  smaller.  They  show  an  unmistakable  elevation,  and  in  some 
instances  a  retinal  vessel  may  be  seen  to  pass  over  them.  The  optic 
nerve  is  always  hypersemic,  but  does  not  show  infiltration.  None  of 
the  choroidal  stroma  appears  clear,  so  far  as  the  degree  of  pigmentation 
natural  to  the  individual  will  permit  a  Judgment. 

These  spots  of  exudation  are  sufficiently  characteristic  to  secure  an 
easy  recognition  of  the  disease,  and  they  suggest  the  features  of  iritis 
gummosa.  The  picture  thus  sketched,  after  two  or  three  weeks,  be- 
gins to  undergo  alterations.  The  yellow  specks  grow  fainter,  but  an 
aggregation  of  pigment  takes  place  at  the  border  of  the  deposit.  After 
a  time,  with  its  more  complete  disappearance,  the  place  it  occupied  in 
the  choroid  is  found  to  have  become  thin  by  the  destruction  of  the 
epithelium  ;  and  finally  the  stroma  of  the  membrane  is  absorbed,  leav- 
ing only  a  dead- white  patch,  whose  border  is  deeply  marked  by  black 
pigment.  In  old  and  severe  cases  the  aspect  of  the  interior  of  the  eye 
40 


626  SYPHILIS  OF  THE  EYE. 

is  most  striking:.  Circular,  oval,  and  roiiiided  white  spots  with  black 
edges  are  clustered  thickly  over  the  surface,  ]iresenting  a  brilliant  con- 
trast to  the  red  color  of  the  choroid,  while  upon  the  apparently  normal 
surface  pigment-dots  are  strewed  about  to  give  evidence  of  the  exten- 
sion of  the  disease  over  all  the  tissue.  There  may  also  be  light-colored 
red  patches,  which  indicate  thinning  <if  the  membrane.  As  above  said, 
these  lesions  may  be  greatest  around  the  ])eri])hery  of  the  choroid,  and 
leave  the  central  and  more  highly  organized  part  of  the  fundus  less 
impaired.  But  vision  is  always  very  badly  reduced,  and  may  be  en- 
tirely lost.  On  the  other  hand,  the  central  region  of  the  fundus  may 
be  alone  atTected,  and  this  virtually  means  blindness.  I  have  seen 
cases  in  wliicii  the  above-described  atrophy  had  spread  over  large  spaces, 
leaving  only  a  few  of  the  greater  choroidal  vessels  as  vestiges  of  the 
vascular  tissue.  The  progress  of  the  above  lesions  may  bo  completed 
in  a  few  mouths,  and  the  eflicacy  of  treatment  is  only  moderately  sat- 
isfactory. 

Another  and  slower  form  of  choroiditis  wdiich  is  seen  in  syphilitic 
patients  consists  in  the  formation  of  patches  of  atrophy  at  the  periph- 
eral part  of  the  fundus  without  previous  deposit  of  lymph.  The  wast- 
ing of  the  membrane  is  a  gradual  process,  and  the  patches  will  present 
a  mixture  of  white,  bordering  upon  a  light-red  surface,  and  the  whole 
bounded  by  a  dark  pigment-line.  The  light-red  part  of  the  patch  indi- 
cates that  here  a  portion  of  the  membrane  yet  survives.  These  patches 
take  on  most  irregular  forms,  and  may  attain  large  size.  They  exhibit 
the  most  varied  mixture  of  black  and  red  and  white,  because  of  the 
diverse  degree  to  which  the  choroid  is  destroyed,  and  the  irregular 
dejDOsit  of  pigment,  both  around  and  upon  the  patches.  They  are 
very  chronic  in  their  development,  and  may  sometimes  be  discovered 
in  an. eye  which  the  patient  supposes  to  be  perfectly  sound.  Indeed, 
direct  vision  may  be  normal,  but  the  visual  field  will  be  encroached 
upon. 

It  is  just  to  state  that  this  kind  of  lesion  is  also  found  in  persons 
who  give  no  evidences  of  syphilis.  The  only  attainable  success  of  treat- 
ment in  these  cases  is  to  delay  or  arrest  the  advance  of  the  disease.  I 
have  never,  however,  convinced  myself  that  a  complete  arrest  has  been 
secured.  The  difficulty  of  following  up  patients  suffering  from  such 
a  chronic  disease  will  be  readily  appreciated.  Several  years  must  pass 
before  a  certain  conclusion  could  be  reached.  Many  varieties  of  ap- 
pearance are  seen  in  choroidal  disease,  and  for  additional  details  the 
reader  is  referred  to  text-books  on  the  eye. 

In  the  first-described  cases  a  somewhat  active  treatment  would  be 
proper  in  the  exudative  stage  ;  that  is,  the  artificial  leech  should  be 
applied  to  the  temple  to  remove  from  two  to  three  ounces  of  blood, 
and  the  patient  be  kept  for  twenty-four  hours  afterward  in  a  dark  room. 
This  may  be  repeated,  according  to  the  strength  of  the  patient,  in  five 


RETINITIS.  027 

or  ten  days.  Dark-blue  glasses  (coquiUes)  should  be  "worn.  The  bow- 
els should  be  mildly  acted  upon.  The  constitutional  treatnnent  for 
syphilis  should  be  pushed  with  as  much  energy  as  the  tone  of  the  sys- 
tem will  bear.  Most  authors  urge  a  speedy  mercurialization,  but  the 
same  discretion  is  imperative  as  in  all  other  cases  of  syphilitic  lesion. 
The  health  of  the  retina  is  not  more  likely  to  survive  the  evil  effects 
of  overdosing  with  mercury  than  of  the  taint  of  syphilis. 

In  the  chronic  forms  of  choroiditis  last  described  only  the  slow  and 
milder  methods  of  constitutional  treatment  are  appropriate.  Local 
treatment,  beyond  protection  against  excessive  light  and  moderation 
in  the  use  of  the  eyes,  is  of  little  value. 

RETINITIS. 

When  produced  by  syphilis,  retinitis  exhibits  only  a  slight  haziness 
and  oedema  of  the  retina,  with  lack  of  sharpness  in  the  outline  of  the 
vessels  and  of  the  optic  disk,  and  hypersemia  both  of  the  retinal  vessels 
and  of  the  optic  nerve.  The  deeper  part  of  the  vitreous  is  hazy.  The 
optic  nerve  is  not  swollen,  there  is  very  little  radiate  striation  of  the 
retina  near  the  nerve  ;  there  are  no  ecchymoses  and  no  thick  jjlaques  of 
yellowish- white  exudation.  The  peripheral  part  of  the  retina  may  re- 
main free  from  perceptible  change,  and  not  only  is  the  disease  usually 
confined  to  the  central  region  of  the  retina,  including  the  nerve,  but  it 
sometimes  is  more  narrowly  localized  to  the  vicinity  of  the  yellow  spot 
itself. 

Because  it  is  thus  inconspicuous,  this  inflammation  is,  on  the  one 
hand,  liable  to  be  overlooked,  and,  on  the  other  hand,  to  be  confounded 
with  such  troubles  as  faint  haziness  of  the  vitreous,  or  of  the  cornea,  or 
perhaps  of  the  lens.  Indeed,  I  have  had  a  case  of  slight  astigmatism  of 
the  mixed  variety,  which,  because  there  had  been  a  syphilitic  history,  I 
for  a  time  mistook  for  retinitis.  The  way  to  escape  such  errors  is  by 
careful  refractive  adjustment  with  the  uj)right  image  to  the  several 
parts  and  depths  of  the  dioptric  media.  Examination  with  the  in- 
verted ophthalmoscopic  image  will  fail  to  assure  a  diagnosis. 

This  kind  of  inflammation  may  attack  one  or  both  eyes,  and  may 
pass  from  one  to  the  other.  It  may  last  a  very  short  time,  say  for 
three  or  four  weeks,  or  it  may  persist  for  several  months.  It  does  not 
always,  but  may  sometimes,  cause  lasting  harm  to  sight.  In  both  the 
transient  and  the  obstinate  cases  it  shows  a  disposition  to  recur.  The 
subjective  symptoms  consist  of  occasional  flashes  of  light  at  the  begin- 
ning of  the  disease,  and  subsequent  dimness  of  sight ;  there  is  no  pain 
nor  lachrymation,  and  but  little  photophobia.  There  is  no  external 
hypergemia. 

Treatment  never  needs  to  be  energetic  :  protection  against  bright 
light  by  colored  glasses,  abstinence  from  use  of  the  eyes,  the  artificial 


628  SYPHILIS   OF   THE   EYE. 

leech,  according  to  the  usual  rules,  two  to  four  time?,  at  intervals  of  a 
week,  constitute  tlie  local  treatment  which  can  be  of  much  avail.  The 
chief  reliance  is  in  the  constitutional  treatment,  according  to  the  prin- 
ciples before  enunciated.  Other  types  occur,  but  need  not  be  de- 
scribed. 

NEURITIS    OPTICA. 

This  is  of  two  varieties  :  1.  That  wliich  is  primarily  in  the  outer 
and  orbital  extremity  of  the  nerve  ;  and,  2.  That  which  is  set  up  by 
intra-cranial  causes.  In  both  cases  the  retina  may  be  more  or  less 
implicated.  The  distinction  between  the  two  "classes  of  cases  can  not 
be  made  with  any  certainty  by  the  ophthalmoscope  alone,  but  the  ques- 
tion of  intra-  or  extra-cranial  origin  of  the  lesion  always  presses  for 
solution.  The  symptoms  which  appear  vary  according  to  the  quality 
of  the  inflammation  and  according  to  its  stage  :  1.  In  simple  cases 
nothing:  is  seen  but  redness  of  the  nerve  surface  and  a  little  fullness 
of  the  central  vessels,  with  scarcely  any  blur  of  the  edge  or  of  the  tis- 
sue. 2.  In  other  cases  the  nerve  is  swollen  to  an  extreme  degree,  its 
structure  infiltrated  and  opaque,  often  striated,  its  color  red  or  gray  or 
leaden,  its  border  partially  or  wholly  obliterated,  its  vessels  tortuous 
and  turgid.  The  aspect  is  then  that  of  the  so-called  "choked  disk," 
and  its  cause  is  usually  intra-cranial.  A  typical  case  of  this  kind  has 
just  come  to  my  notice  in  a  man  lying  in  Bellcvue  Hospital  with  mani- 
fest brain-disease,  as  denoted  by  the  partial  coma  and  delirium,  the 
headache,  the  tenderness  of  the  skull  on  pressure,  and  the  evident  peri- 
osteal swellings  of  the  forehead  and  vertex.  Both  optic  nerves  are  in 
the  condition  described,  and  he  has  the  history  of  syphilis  ;  a  gummy 
tumor  in  the  substance  of  the  brain,  or  basilar  meningitis,  may  cause 
the  same  result.  3.  In  other  cases  of  brain-syphilis  the  optic  nerves  be- 
come impaired,  and  exhibit  to  inspection  only  a  white  color  and  woolly 
texture  with  a  little  blur  of  the  edge — the  vessels  being  small.  There 
may  perhaps  be  a  doubt  whether  a  faint  degree  of  hyperajmia  has  not 
preceded  this  condition  ;  but,  if  it  has,  its  duration  has  been  extremely 
brief.  The  look  which  the  nerve  in  these  cases  possesses  is  difficult  to 
describe,  because  the  change  is  in  texture. 

In  these  cases,  as  we'll  as  in  tlie  nerve-lesions  before  mentioned,  it 
is  extremely  important  to  determine  the  extent  of  the  field  of  vision. 
It  will  be  found  in  almost  all  instances  to  be  curtailed  at  some  part. 
Very  common  is  it  to  find  irregular  hemiopia  or  the  loss  of  a  quadrant 
of  the  field  ;  concentric  limitation  is  not  so  common. 

Prognosis  in  these  afEections  is  never  good,  but  a  valuable  degree 
of  sight  is  often  preserved  or  recovered. 

Treatment  is  mainly  constitutional. 


AFFECTIONS   OF  THE   MOTOR  NERVES.  029 

AFFECTIONS    OF    THE    MOTOR    NERVES. 

An  extremely  common  effect  of  syphilis  is  to  disturb  tlie  function 
of  some  of  the  motor  nerves  of  the  eye  ;  one  muscle,  or  any  number  of 
the  muscles,  may  be  paralyzed.  Inasmuch  as  the  third  (motor  com- 
munis oculi)  supplies  four  muscles,  the  eye,  when  it  is  impaired,  is 
most  helpless  ;  but  separate  twigs  may  be  singled  out  while  others  are 
undisturbed.  If  the  whole  nerve  is  at  fault,  the  eye  stands  at  the  outer 
angle,  is  incapable  of  motion  up  or  down,  and  can  not  turn  inward 
farther  than  the  median  line ;  the  upper  lid  droops  and  can  not  be 
lifted.  It  can  be  carried  farther  outward  by  the  external  rectus,  and 
under  influence  of  the  superior  oblique  will  make  some  rotatory  move- 
ments. The  pupil  will  be  in  medium  dilatation  and  the  function  of 
accommodation  paralyzed.  Diplopia  will  not  commonly  be  noticed, 
even  if  the  lids  be  opened,  because  the  two  images  are  so  far  asunder 
as  not  to  attract  attention.  As  the  nerve  begins  to  recover  and  the 
eye  to  regain  mobility,  diplopia  will  become  annoying  and  the  images 
will  be  crossed. 

If  the  sixth  nerve  is  paralyzed,  the  eye  stands  in  abnormal  conver- 
gence, because  the  abductive  power  of  the  external  rectus  is  destroyed. 
Double  images  then  are  correspondent  (homonymous),  and  are  most 
annoying  for  distant  objects,  while  an  object  brought  very  near  the 
eye  may  be  seen  correctly.  If  the  fourth  nerve  is  paralyzed,  a  superfi- 
cial inspection  may  fail  to  recognize  the  defect  in  mobility.  It  will  be 
detected  with  certainty  by  careful  study  of  the  double  images.  To  do 
this  it  is  better  to  take  a  lighted  candle  for  an  object,  and  to  put  a 
slip  of  red  glass  before  one  eye.  There  may  be  no  dij^lopia  in  the  field 
above  the  horizontal  line,  but,  as  the  eyes  descend,  double  vision  occurs, 
one  image  (the  false  one)  being  below  the  other,  and,  as  the  object  is 
carried  to  the  temporal  side  of  the  affected  eye,  the  images,  besides 
being  above  one  another,  separate  laterally,  the  false  one  being  farther 
to  the  nasal  side.  Another  fact  about  the  false  image  is,  that  it  is  not 
vertical,  but  leans  so  that  its  top  inclines  inward.  Without  study  of 
the  double  images,  a  strong  suspicion  of  paralysis  of  the  fourth  nerve 
may  be  awakened  by  noticing  that  the  eyeball  when  caused  to  move  in 
a  straight  line  below  and  parallel  to  the  horizon,  on  reaching  the  mid- 
dle of  the  orbit  in  its  excursion  outward,  makes  a  twitch  and  an  im- 
perfect rotation  of  the  cornea,  and  also  fails  to  go  as  easily  and  com- 
pletely to  the  outer  angle  as  the  healthy  eye. 

Patients  who,  from  any  kind  of  paralysis,  have  diplopia,  are  thereby 
much  disturbed,  sometimes  having  nausea  and  headache,  while,  to  nse 
their  eyes,  they  must  either  shut  one,  or  correct  the  double  sight  by 
some  twist  of  the  head,  or  by  means  of  properly-adjusted  prisms.  The 
use  and  choice  of  prisms  is  a  subject  not  suited  to  the  present  treatise, 
and  for  which  the  reader  is  referred  to  the  works  on  ophthalmology. 


630  SYPniLis  OF  THE  eye. 

During  the  early  stages  of  tlie  trouble,  the  proper  treatment  is 
counter-irritation  to  the  temples,  the  faradic  eleetrie  current,  and  con- 
stitutional remedies.  After  a  number  of  months  have  passed,  if  some 
imperfection  of  motion  remain,  the  use  of  prisms,  or  tbe  performance 
of  tenotomy,  or  of  some  oi)eration  on  the  muscles,  may  be  resorted  to. 

Periosteal  ixflammatiox  of  the  orbit  does  not  often  occur,  but 
some  symptoms  which  it  causes  are  worth  attention.  If  it  affect  the 
deep  parts  of  the  cavity,  it  may  cause  disturbance  in  the  function  of 
some  of  the  muscles,  and  hence  diplopia  ;  or,  if  attended  by  serous  or 
other  effusion  in  sutticient  quantity,  may  produce  cxo])hthalmus,  and 
visible  signs  of  inflammation  in  the  globe  and  eyelids. 

This  I  have  seen,  in  the  most  emphatic  character,  in  a  case  where 
the  anterior  part  of  the  orbit  was  tlic  seat  of  periostitis.  So  great  were 
the  congestion,  oedema,  and  secretion  from  the  conjunctiva,  and  the 
swelling  of  the  lids,  that  the  disease  resembled  acute  purulent  conjunc- 
tivitis. The  pain  which  the  patient  suffered  was  intense,  and  greater 
than  is  common  in  conjunctival  inflammations.  This  fact,  and  the 
presence  of  an  eruption  on  the  face,  led  to  digital  exploration  of  the 
margin  of  the  orbit.  The  exquisite  tenderness  at  once  revealed  the 
true  nature  of  the  diseased  action,  and  indicated  the  need  of  constitu- 
tional as  well  as  of  local  treatment.  After  one  eye  had  suffered  in  this 
way  between  two  and  three  weeks,  the  other  was  similarly  though  less 
severely  attacked,  and  in  this  instance  the  onset  of  the  trouble  was 
distinctly  seen  to  be  in  the  lining  membrane  of  the  orbit,  and  from  it 
acute  inflammation  was  propagated  to  the  external  structures  of  the 
globe.  There  was  no  evidence  of  gummy  exudation.  The  treatment; 
of  the  case  consisted  in  leeches  to  the  temples,  iced-water  compresses 
changed  so  often  as  to  be  constantly  cold,  application  of  a  solution  of 
nitrate  of  silver — ten  grains  to  the  ounce — to  the  everted  palpebral  con- 
junctiva, at  first  twice  and  afterward  once  daily,  and  hypodermic  in- 
jections of  sulphate  of  morphine  :  besides  this,  very  high  doses  of  iodide 
of  potassium,  at  one  time  reaching  three  drachms  a  day,  were  employed, 
but  the  benefit  derived  from  the  heroic  doses  did  not  appear  to  be  great. 
The  patient  recovered  without  damage  to  her  eyes. 

As  to  gummy  tumors  growing  in  the  orbit,  nothing  special  need  be 
said  :  that  their  bulk  must  displace  the  eyeball,  and  that  they  must 
otherwise  interfere  with  its  functions,  is  self-evident. 

There  may  be  nodes  upon  the  walls  of  the  orbit,  and  necrosis  or 
caries  are  not  infrequent ;  abscess  forms  ;  a  fistula  often  remains  ;  fre- 
quently the  lids  become  distorted  by  adhesions  of  the  skin.  Some- 
times these  inflammations  are  attended  with  severe  constitutional 
disturbance,  and  there  is  also  danger  of  implication  of  the  adjacent 
cerebral  structures.  Treatment  must  be  vigorously  antispecific.  Sur- 
gical proceedings  are  often  required  to  remove  dead  bone,  to  give  vent 
to  matter,  to  correct  ectropium,  etc. 


PERIOSTITIS   ORBITAL.  031 


CHAPTER  IX. 

SYPHILIS  OF  THE  EAR. 

Syphilis  as  affecting  the  Externa),  Middle,  and  Internal  Ear. 

The  affections  of  the  ear  caused  or  modified  by  syphilis  are  con- 
veniently considered  by  arranging  them,  in  accordance  with  the  anat- 
omy of  the  organ,  into  those  of  the  external,  middle,  and  internal 
ear. 

The  integument  of  the  external  ear  is  liable  to  be  involved  in  the 
cutaneous  affections  of  syphilis,  its  substance  to  be  destroyed,  or  its 
cartilage  eaten  away  by  syphilitic  ulcers  and  gummy  tumors.  The 
auditory  canal  may  be  invaded  by  mucous  patches,  sometimes  showing 
exuberant  granulations,  by  erythematous  spots,  or  by  pustules.  A  dry 
exfoliation  of  portions  of  its  skin  is  not  uncommon,  together  with  a 
change  in  the  quality  of  the  sebaceous  matter,  so  that  the  latter  accu- 
mulates in  a  scabby  way  over  the  drum-head  and  in  the  auditory  canal 
as  well.  The  cerumen  may  also  become  impacted.  Bony  growths — 
exostoses  and  hyperostoses — in  the  external  auditory  canal  may  also 
be  encountered  in  the  course  of  syphilis,  but  Eoosa*  believes  that  these 
growths  occur  quite  as  commonly  as  the  result  of  local  irritation  iu 
persons  who  have  never  had  syiihilis. 

The  middle  ear  may  be  involved,  in  the  course  of  secondary  disease, 
by  an  inflammation  of  its  lining  membrane.  This  inflammation  is  not 
attended  by  increase  of  secretion  (catarrh  of  the  middle  ear),  but  by  a 
proliferation  of  tissue,  which  does  not  tend  to  suppuration  but  to 
thickening  of  the  drum-head,  and  to  adhesions  between  the  ossicula 
and  the  walls  of  the  tympanum.  Wilde  f  described  this  affection 
under  the  name  of  "  syphilitic  myringitis,"  and  he  believed  that  it 
was  characterized  by  the  relative  insignificance  of  the  pain,  in  com- 
parison with  that  felt  in  the  same  disease  when  not  due  to' syphilis. 
Bumstead,J  however,  thinks  that  the  absence  of  local  pain  is  not  a 
characteristic  of  the  malady.  Roosa*  believes  that  there  are  no  pecul- 
iar aural  symptoms  in  this  form  of  disease.  He  remarks,  however, 
that  "  a  syphilitic  diathesis  seems  to  cause  the  proliferation  of  tissue 
to  be  more  rapid."  He  agrees  with  Schwartze,  of  Halle,  who  thinks 
that  periostitis  of  the  middle  ear  is  at  the  basis  of  these  cases. 

Local  bloodletting,  the  warm  douche,  and  opium  for  pain,  will, 
with  the  ordinary  antisyphilitic  treatment,  usually  master  the  affec- 

*  "  Diseases  of  the  Ear,"  p.  402.  %  "Venereal  Diseases,"  p.  590. 

f  "  Aural  Surgery,"  English  edition,  p.  260.  *  Loc.  ciL,  p.  286. 


632  srrniLis  of  special  tissues  and  organs. 

tion,  if  employed  during  the  early  stages.  It  will  probably  also  be 
necessary  to  inllate  the  ear  by  Politzer's  method,  in  order  to  prevent 
the  formation  of  adhesions  in  the  tympanic  cavities. 

Young  children  affected  with  congenital  syphilis  may  be  attacked 
by  a  catarrh  of  the  middle  ear,  which  resists  local  and  constitutional 
treatment  very  obstinately — that  is  to  say,  intra-aurieular  adhesions 
occur,  the  drum-head  becomes  sunken,  the  nerve  is  secondarily  in- 
volved, and  the  imjiairment  of  hearing  often  remains  permanent.* 
The  mouth  of  the  Eustachian  tube  is  sometimes,  but  rarely,  the  seat 
of  ulceration,  and  thus  im2)airnient  of  the  hearing  may  be  caused. 
Permanent  loss  of  hearing  is  sometimes  due  to  cicatrization  of  the 
pharyngeal  orifice  of  the  tube. 

The  portio  mollis  of  the  seventh  pair  may  be  the  seat  of  special 
disease,  and  periostitis  of  the  labyrinth,  as  well  as  gummy  tumors, 
may  occur. 

It  is  probable  that  hypersemia  of  the  membranous  labyrinth  may 
occur  in  the  course  of  syphilis.  This,  if  unchecked,  may  lead  to 
atrophy  of  the  tissues. 

The  use  of  the  tuning-fork  will  be  of  efficient  aid  in  the  differential 
diagnosis  of  cases  in  which  there  is  doubt  as  to  whether  the  loss  of 
hearing  depends  upon  disease  of  the  middle  or  internal  ear. 

If  the  acoustic  nerve  be  affected,  the  tuning-fork  C"  will  be  heard, 
if  at  all,  better  and  longer  when  placed  in  vibration,  and  held  in  front 
of  the  external  meatus,  than  when  its  handle  is  placed  on  the  mastoid 
process  ;  that  is  to  say,  the  aerial  conduction  will  be  better  than  that 
by  bone.  If  the  deafness  be  profound,  the  tuning-fork  will  not  be 
heard  at  all.  f 


CHAPTER  X. 

SYPHILIS  OF  SPECIAL    TISSUES  AWB   ORGANS. 

Syphilis  of  the  Nails.— Dactylitis.— Syphilis  of  Tendons,  Sheaths  of  Tendons,  and  Aponeuroses. — 
Syphilis  of  Muscle.— Syphilis  of  Joints. — Syphili.s  of  Bone. — Syphilis  of  Cartilage  —Syphilis  of 
Lymphatic  Glands.— Syphilis  of  the  Mammary  Gland. 

Syphilis  of  the  Nails. — Mucous  patches  are  sometimes  seen 
under  the  free  border  of  the  nail.  A  whitish  or  brownish,  badly- 
smelling,  characteristic  secretion  is  furnished  by  such  patches.  With 
the  earlier  eruptions  on  the  skin,  the  nails  are  liable  to  lose  something 
of  their  luster.  They  are  apt  to  become  seamed  by  slight  longitudinal 
furrows,  brittle,  friable,  cracked,  and  shaling  off  at  their  extremities, 
sprinkled  with  an  abundance  of  white  points  showing  an  imperfect 

*  Roosa,  \oc.  dt.  f  Roosa,  sixth  edition,  p.  610. 


THE  NAILS.  633 

epithelial  formation.  This  dry  form  of  onychia  may  cease  at  any  pe- 
riod of  its  progress,  healthy  nail  growing  out  from  tlie  matrix,  or  it 
may  go  on,  very  rarely,  to  a  complete  shedding  of  the  nail  by  an  un- 
dermining process,  commencing  most  often  at  the  side,  sometimes  in 
front,  most  rarely  at  the  back  of  the  nail  in  the  region  of  the  lunula. 
When  the  customary  undermining  process  begins  at  the  side  of  the 
nail,  the  nail  itself  thickens,  becomes  friable,  brittle,  dirty  in  color, 
and  the  cutaneous  fold  at  the  side  thickens  and  cracks  at  times  pain- 
fully. Sometimes  the  entire  nail  thickens,  becoming  rough,  brittle, 
discolored.  During  the  secondary  period  of  syphilis  specific  onychia 
is  sometimes  encountered  upon  the  tingers,  more  often  upon  the  toes. 
It  is  not  uncommonly  symmetrical,  the  same  toe  on  each  foot  being 
involved.  Spontaneously,  or  after  slight  injury,  pain  is  felt  some- 
where about  the  border  of  the  nail.  The  painful  point  becomes  swollen 
and  of  a  reddish-brown  color.  This  goes  on  to  ulceration  at  the  edge 
of  the  nail,  and  spreads  around  it.  The  surface  of  the  ulcer  is  moist, 
brownish,  fungous ;  the  secretion  ichorous,  fetid.  The  nail  loosens, 
superficial  ulceration  progresses  beneath  it.  The  nail,  with  the  prog- 
ress of  the  affection,  sometimes  softens  and  falls  away,  its  place  being 
supplied  by  the  ulcer,  only  a  small  portion  of  nail  remaining  at  the 
point  occupied  by  the  lunula.  The  whole  end  of  the  toe  or  finger  be- 
comes engorged,  violet-colored,  very  painful ;  deep  inflammation,  with 
necrosis  of  the  ungual  phalanx,  may  follow.  Instead  of  reaching  this 
extreme,  the  affection  sometimes  remains  confined  to  a  portion  of  the 
circumference  of  the  nail.  Here  the  skin  is  swollen,  livid,  ulcerated  ; 
the  nail  seeming  to  act  like  a  foreign  body,  preventing  repair.  All  the 
forms  of  syphilitic  onychia  progress  very  slowly,  but  terminate  habitu- 
ally in  recovery. 

Diagnosis. — The  dry  form  of  secondary  syphilitic  onychia  must  be 
distinguished  from  the  somewhat  similar  condition  found  in  eczema, 
psoriasis,  and  parasitic  affections,  by  the  history  and  concomitant  symp- 
toms. The  ulcerated  form  of  secondary  onychia  is  distinguished  from 
ordinary  in-growing  nail,  run-round,  etc.,  by  this,  that  in  it  ulcera- 
tion and  inflammation  take  place  primarily  in  the  matrix  of  the  nail, 
while  in  the  latter  affection  they  commence  first  in  the  outlying  tissues. 
Tertiary  onychia  is  a  gummy,  destructive  inflammation  of  the  matrix 
in  a  more  severe  form.  It  has  the  same  general  characters  as  the  sec- 
ondary affection,  only  more  severely.  It  usually  commences  in  the 
matrix,  at  some  point  along  the  lunula  ;  the  nail  thickens  and  softens, 
finally  falls,  while  destructive  ulceration  is  slowly  advancing,  involv- 
ing the  deeper  tissues  in  an  irregular  manner,  jaerhaps  attacking  the 
bone. 

Treatment. — The  constitutional  treatment  is  regulated  accordingly 
as  the  disease  partakes  more  of  the  secondary  or  tertiary  tyi^e.  Lo- 
cally cleanliness,  removal  of  nail  and  loosened  portions  of  nail  which 


634  SYrriiLis  of  srECUL  tissues  axd  organs. 

act  as  foreign  bodice:,  nitrate  of  silver  for  exuberant  granulations, 
iodoform  pure  or  diluted  for  ulcerated  surfaces,  or  black  or  mild  yel- 
low-wash. 


SYPHILIS   OF   THE    FINGERS    AND    TOES. 

Dactylitis  {SaKTvXos,  a  dijif — finger  or  toe). — This  rare  affection 
requires  a  special  description.     But  few  cases  of  it  are  on  record.* 

Dactylitis  is  gummy  in  character,  and  hence  belongs  to  the  later 
stages  of  syphilis.     Taylor  makes  two  varieties  : 

1.  Subcutaneous  and  articular,  the  bone  not  being  much  affected. 

2.  Nearly  confined  to  the  bone  and  joint. 

1.  The  first  form  comes  on  rapidly  or  slowly  ;  diffuse  gummy  infil- 
tration takes  place  subcutaneously,  involving  the  periosteum  upon  the 
first  phalanx  (most  often),  but  perhaps  including  the  whole  lingers. 
The  swelling  usually  terminates  abruptly,  as  a  more  or  less  perfect 
ridge  at  the  articulation  of  the  finger  or  toe  with  the  hand  or  foot,  and 
is  most  marked  on  the  dorsum.  The  swelling  is  sometimes  very  great, 
so  as  mechanically  to  impede  motion,  but  there  is  no  complaint  of 
pain.  The  skin  is  natural  or  slightly  bluish,  from  venous  obstruction. 
The  swelling  is  firm,  resistant  to  the  touch.  The  fibrous  structures 
around  the  joint  next  become  also  involved.  The  synovial  membrane 
seems  to  escape,  there  being  no  effusion  into  the  joint  unless  the  bone 
is  also  implicated.  After  a  variable  time  crepitation  (rather  rough) 
may  be  observed  in  the  joint.  Disintegration  of  the  joint  is  possible, 
the  skin  ulcerating  over  it.  The  bones,  esjoecially  near  the  affected 
joint,  also  enlarge  slightly,  participating  in  the  disease.  The  malady 
runs  a  slow  course,  perhaps  relapsing  several  times  after  apparent  ef- 
forts at  repair,  but  yields  in  the  long-run  to  specific  remedies,  leaving 
behind  more  or  less  disturbance  about  the  function  of  the  joint,  accord- 
ing to  the  degree  to  which  the  disorganization  of  its  tissues  has  ])ro- 
gressed.     In  bad  cases  anchylosis  would  follow. 

2.  In  the  second  form  the  phalanx,  usually  the  first,  is  primarily 
attacked  in  its  bone  as  a  gummy  osteo-periostitis,  or  an  interstitial 
gummy  osteo-myelitis.  f 

The  swelling  is  sometimes  very  considerable.  In  Berg's  J  case  the 
finger  had  a  circumference  of  five  inclics  (Fig.  113). 

*  R.  W.  Taylor's  article  in  the  "  American  .Journal  of  Dermatology  and  Syphilog- 
raphy,"  January,  1871,  is  an  excellent  presentation  of  the  subject. 

f  Sometimes  many  bones  on  both  hands  are  involved  in  different  stages  of  the  bony 
changes,  constituting  dactylitis.  In  a  patient,  brought  for  advice  by  Dr.  Wylie,  several 
of  the  first  and  some  of  the  second  phalanges,  as  well  as  several  of  the  metacarpal  bones 
of  both  hands,  showed  the  characteristic  changes.  In  another  (personal)  case,  the  meta- 
carpo-phalangeal  joint  of  the  thumb  and  great  toe  on  the  right  side  were  alone  involved. 

X  "  Fall  von  gummoscr  (syphilitischer)  Dactylitis,"  "'  Arch,  of  Derm,  and  Syph.,"  No.  2, 
1870,  and  Taylor,  loc.  cit. 


SYPHILITIC   DACTYLITIS. 


035 


111  this  second  class  of  cases  the  swelling  is  mainly  confined  to  the 
phalanx  (most  markedly  its  dorsal  surface),  and  to  the  joint  afTected, 
as  there  seems  to  be  little,  sometimes  no  disease  of  the  more  superficial 
structures.    The  affection  may  run  an  acute  or  a  chronic  course.    The 


Fig.  113. 


integument  becomes  stretched  and  tense  by  the  subjacent  swelling. 
Its  color  grows  pink  or  red,  and  it  may  be  for  a  time  sensitive,  the 
result  of  continued  pressure.  The  nail  does  not  suffer,  even  when  the 
last  phalanx  is  involved.  Appearances  similar  to  those  found  in  dry 
caries  have  been  encountered  after  death  in  the  affected  phalanges. 
The  gummy  deposit,  after  producing  great  swelling  of  the  bone  by  its 
infiltration,  undergoes  absorption  without  suppuration,  as  in  dry  caries, 
and  results  in  loss  of  substance  of  the  bone,  which  is  not  replaced  by 
new  tissue.  If  very  rapidly  formed,  the  gummy  deposit,  here  as  else- 
where, may  undoubtedly  break  down,  and  be  eliminated  externally. 
In  this  second  form  of  the  disease,  changes  sometimes  occur  in  the  joint 
similar  to  those  already  described  for  the  first  variety.  Considerable 
effusion  may  take  place.  The  amount  of  pain  complained  of  is  very 
slight,  as  in  other  syphilitic  joint-affections. 

As  a  final  result  of  the  absorption  of  the  gummy  deposit,  the  shaft 
of  the  bone  becomes  shortened,  or  sliglitly  attenuated.  In  McCready's 
case  (Fig.  114)  a  whole  phalanx,  its  joint,  and  a  portion  of  the  meta- 
carpal bone  disappeared.  From  these  changes  great  deformity  may 
•result,  the  fingers  or  toes  becoming  shortened  and  distorted.  False 
joints  form  between  the  two  ends  of  a  phalanx  which  have  been  sepa- 
rated by  absorption  of  a  portion  of  the  shaft  of  the  bone.  The  in- 
tegument in  such  cases  contracts,  and  adapts  itself  to  the  altered  con- 
dition of  affairs,  thus  materially  strengthening  any  false  joint  that  may 
form.  The  sheaths  of  the  tendons  have  not  been  involved  in  any  of 
the  recorded  cases. 

A  number  of  observers  have  seen  this  malady  in  inherited  syphilis. 
I  have  seen  it  twice,  once  in  quite  a  small  infant,  again  in  a  boy  of 
sixteen. 


636 


SYPUILIS   OF  SrECIAL   TISSUES  AND   ORGANS. 


Diagnosis. — Absence  of  pain  distiiiguislics  tlio  earlier  stages  of  dac- 
tylitis from  inilamniatory  disturbances  and  gout.  In  rheumatic  ar- 
thritis the  sheaths  of  the  tendons  generally  suii'er  (the  flexors),  dis- 
torting the  lingers,  and  tophi  are  usually  doi)ositod  about  the  joints. 


i^iim^O'Ucu^' 


Fig.  114  (Taylor). 

I  have,  however,  seen  once  a  case  of  rheumatic  gout  of  one  hand  in- 
volving several  articulations  in  which  all  the  physical  appearances  of 
the  syi^hilitic  variety  were  present,  and  only  the  histoiy — the  duration 
of  the  disease,  ten  or  twelve  years,  with  moderate  pain  and  consider- 
able stiffness  all  the  time,  the  existence  of  other  evidences  of  gout  and 
the  absence  of  syphilis,  together  with  failure  of  specific  treatment — 
made  the  diagnosis  of  syphilis  impossible.  Enchondroma  grows  slowly 
as  a  hard,  well-defined  tumor,  prefers  the  palmar  to  the  dorsal  surface, 
dactylitis  occupying  more  often  the  dorsum.  The  characters  of  dac- 
tylitis as  described,  together  with  the  syj)hilitic  history,  would  serve 
to  distinguish  it  from  ordinary  periostitis,  and  from  strumous  disease 
of  the  bono. 

The  prognosis  is  good  if  taken  early,  although  the  ordinary  course 
of  the  disease  is  slow. 

Treatment  is  that  of  tertiary  syphilis.  Local  inunction  of  mercu- 
rial ointment,  with  large  doses  of  the  iodide  of  potassium  internally, 
acts  efficiently  if  commenced  early.  If  started  too  late,  some  absorp- 
tion of  tissue,  shortening  of  finger,  or  anchylosis  of  joint  is  inevitable. 
Local  surgical  measures  are,  as  a  rule,  unnecessary,  except  rest  and 
soothing  applications  to  meet  inflammatory  manifestations. 


SYPHILIS   OF   TENDONS.  G37 

SYPHILIS  OF  THE  TENDONS,  SHEATHS  OF  TENDONS,  AND 
APONEUROSES. 

Verneuil*  first  called  special  attention  to  serous  effusions  into  the 
sheaths  of  tendons  (extensors)  on  the  dorsum  of  the  carpus  and  meta- 
carpus, on  both  or  on  one  side,  due  to  syphilis.  Effusion  comes  on 
promptly,  fluctuation  can  be  distinguished,  there  is  no  change  in  the 
color  of  the  integument.  The  shape  of  the  swelling  is  triangular, 
with  the  base  toward  the  fingers.  It  does  not  extend  beyond  the  dor- 
sal ligament.  There  is  slight  pain  on  pressure,  with  a  little  weakness 
and  inconvenience  of  movement.  The  affection  is  secondary,  and  a 
few  days  of  internal  mercurial  treatment  causes  it  to  vanish.  Verneuil 
calls  it  dorsal  hygroma. 

Fournier  f  speaks  of  a  syphilitic  affection  of  the  sheaths  of  tendons 
not  only  about  the  wrist,  but  also  about  the  ankle,  foot,  knee,  elbow, 
etc.,  and  thinks  that  the  sheath  of  any  tendon,  superficial  or  deep, 
may  be  affected  by  syphilis  early  in  the  secondary  period.  Either 
effusion  takes  place  without  any  redness  of  the  cuticle  or  some  redness 
of  the  latter,  and  surrounding  oedema  with  considerable  pain  may  be 
found.  Fournier  believes  that  many  of  the  pains  found  early  in  sec- 
ondary syphilis  about  the  knee,  and  especially  about  the  elbow,  are 
due  to  affections  of  tendons  of  deep-seated  muscles,  laying  stress  par- 
ticularly upon  pain  in  the  bend  of  the  elbow  increased  by  pressure, 
having  its  real  seat  not  in  the  bone  nor  in  the  joint,  but  in  the  tendon 
of  the  biceps. 

Both  tendinous  and  aponeurotic  tissue  may  also  become  the  seat  of 
syphilitic  lesion,  either  as  interstitial  thickening  from  hyjoerplasia  of 
connective-tissue  elements  in  a  diffused  manner,  capable  of  thorough 
organization,  or  as  a  distinct  gummy  tumor.  The  tendons  are  more 
often  involved  than  the  aponeuroses.  Gummy  tumors  of  tendons 
sometimes  are  absorbed  and  calcify  without  destroying  the  function 
of  the  tendon.  The  more  dense  and  resisting  the  tendon  the  more 
exposed  does  it  seem  to  be  to  gummy  tumor — tendo  Achillis,  tendon 
of  quadriceps  extensor  femoris,  etc,  A  tumor  of  this  latter  tendon  is 
noticed  by  Arrzomann,J  which  lighted  up  hydrarthrosis,  and  might 
have  passed  readily  for  a  white  swelling.     I  have  seen  similar  cases.- 

Oummy  tumors  of  teiidons  are  not  painful.  Sometimes  they  are 
so,  when  the  muscle  contracts  ;  hence  such  a  muscle  usually  refuses  to 
act  at  all  after  a  time.  The  tumors  can  generally  be  felt  under  the 
skin  upon  the  tendon  as  hard,  circumscribed  masses.  If  they  go  on 
to  soften,  the  skin  reddens,  breaks,  and  a  gummy  ulcer  is  left.     These 

*  "  De  I'Hydropisie  des  Gaines  tendineuses  des  Extenseurs  des  Doigts  dans  la  Syphilis 
secondaire,"  "  Gaz.  Hebdom.,"  1868,  p.  609. 

f  "  Note  sur  les  Lesions  des  Gaines  tendineuses  dans  la  Svpliilis  secondaire,"  "  Gaz. 
Hebdom.,"  1868,  p.  645. 

X  Th^se  de  Paris,  1858. 


G38  SYniiLis  OF  special  tissues  and  organs. 

tumors  are  important,  from  their  liability  to  be  mistaken  at  first  for 
the  little  serous  swellings  found  often  u])on  the  tendons  of  the  lingers, 
called  ganglia.  The  history  and  progress  of  the  affection  are  the  only 
means  of  making  a  diagnosis.  Ganplia  may  be  ruptured  by  a  blow, 
not  so  a  gummy  tumor. 

Treatment  of  tertiary  syphilis  is  usually  speedily  curative. 

SYPHILIS  OF  THE  BURS-ffi. 

The  bursee  may  suffer  in  secondary  and  in  tertiary  syjihilis.  Ver- 
neuil*  has  reported  a  case  of  simple  dropsy  of  the  bursa  behind  the 
olecranon  in  secondary  syphilis.  I  f  reported  a  number  of  cases  of  ter- 
tiary disease  of  the  bursa?,  some  of  which  were  admirable  specimens  of 
housemaid's  knee.  Fournier  J  has  also  described  these  affections,  and 
Moreau  ^  as  well.  All  modern  authors  allude  to  this  condition,  which 
is  not  very  uncommon.  The  bursa  in  front  of  the  patella  is  most 
often  implicated  in  tertiary  disease  ;  next,  a  bursa  on  the  inner  side 
of  the  knee ;  then  the  one  behind  the  olecranon.  The  other  bursee 
are  less  often  attacked.  The  tertiary  affection  usually  comes  on  sev- 
eral years  after  infection.  The  bursa  may  be  j)rimarily  involved  or 
implicated  by  extension  of  gummatous  disease  in  the  skin  and  subcu- 
taneous tissues.  The  termination  is  by  softening  and  discharge,  leav- 
ing a  ragged  cavity  or  scar  tissue  Avith  fistulas.  The  affection  is  always 
painless,  indolent  in  character.  The  prognosis  is  good.  Prolonged 
treatment  is  required,  mixed  in  character,  with  the  iodides  in  excess. 

SYPHILIS  OF  THE  MUSCLES. 

Besides  the  muscular  pains  of  early  syphilis  felt  in  the  legs,  loins, 
thighs,  etc.,  there  are  three  forms  of  syphilitic  myositis  : 

(«)  Congestive. 

{b)  Diffuse  interstitial. 

(c)  Gummatous. 

ia)  Congestive. — This  malady,  first  described  by  Notta  I  as  a  syphi- 
litic affection  of  the  biceps,  has  been  more  fully  worked  out  by  Mau- 
riac.''^  Van  Harlingen  ^  has  also  studied  the  subject  in  connection 
with  some  cases.  The  biceps  and  triceps  are  most  commonly  imi)li- 
cated,  but  other  muscles,  notably  the  flexors,  also  may  suffer.  The 
malady  appears  most  commonly  between   the  sixth  and  the   tenth 

*  "  Gaz.  Ilebdom.,"  January  10,  1873,  obs.  iv. 
t  "  Am.  .Tour.  Med.  Sci.,"  April,  1876,  p.  349. 
X  "  Syphilis  chez  la  Femmc,"  p.  70B. 

*  Th^se  de  Paris,  1873. 

I  "Archiv.  G6n.,"  1850,  p.  413. 

•^  "  Le9ons  sur  les  myopathies  .syphilitiques,"  Paris,  1878. 

0  "Am.  Jour.  Med.  Sci.,"  April,  1880,  p.  399. 


SYPHILIS   OF  THE   MUSCLES,  039 

month.  It  seems  to  bo  more  common  in  individuals  whose  eruptions 
have  been  dry,  and  who  are  subject  to  muscular  pains.  It  commences 
gradually,  and  advances  slowly.  There  is  a  gradual  flexure  of  the  fore- 
arm (if  the  biceps,  as  is  commonly  the  case,  is  involved),  which  be- 
comes painful  when  efforts  are  made  to  forcibly  straighten  the  arm. 
When  the  triceps  is  similarly  affected,  the  elbow  becomes  fixed  (mus- 
cular anchylosis).  The  tendon  of  the  biceps  is  felt  short,  hard,  rigid, 
prominent.  Sometimes  there  is  a  dull  pain  in  the  muscle  at  night. 
The  tendon  of  the  muscle  involved  is  sensitive  to  pressure.  Untreated, 
the  malady  lasts  months,  sometimes  years,  but  the  muscular  structure 
does  not  atrophy.  There  may  be  remissions  and  relapses.  Mixed 
treatment  is  most  effective.  Fournier*  has  considered  this  malady, 
and  Cesbon.f 

{b)  Diffuse  Interstitial  Myositis. — This  form  here,  as  elsewhere, 
consists  in  a  hyperplasia  of  connective-tissue  elements.  It  takes  place 
between  the  muscular  fibers.  The  new  connective  tissue  atrophies, 
draws  together  in  its  contractions  uijon  the  muscular  elements,  and 
thus  causes  their  wasting  and  destruction.  Virchow  |  has  made  a  pro- 
found study  of  this  condition.  He  compares  the  muscular  atrophy  to 
the  same  result  following  rheumatic  inflammation.  Any  muscle  may 
suffer,  but  it  seems  to  be  more  common  in  the  extremities.  Buisson 
believes  that  stricture  of  the  rectum  may  be  caused  by  syphilitic  myo- 
sitis. Atrophy  is  the  result  if  untreated.  There  is  an  ill-defined 
swelling  of  the  muscle,  usually  attended  by  slight  pain  and  some  lack 
of  proper  function  on  the  part  of  the  muscle,  which  is  somewhat  short- 
ened, but  may  be  extended,  although  such  extension  is  painful. 

Treatment  commenced  early  has  great  power  over  this  affection  ; 
later,  during  the  atrophic  stage,  none  whatever.  Total  atrophy  of  the 
muscle,  with  shortening  and  consequent  distortion  of  joints,  is  the 
final  result  of  interstitial  syjjhilitic  myositis  unreli'eved  by  treatment. 

(5)  Gummy  Tumoe  of  Muscle. — This  condition  differs  from  the 
preceding  only  in  this  :  that  the  new  material  is  circumscribed  instead 
of  diffused,  and  is  much  more  prone  to  soften  and  discharge  externally. 
Such  tumors,  commencing  in  a  muscle,  may  subsequently  involve  other 
more  important  parts,  as  gummata  of  the  tongue,  palate,  pharynx, 
larynx,  which  may  primarily  originate  in  muscular  tissue,  or  rather 
its  interstitial  connective-tissue  elements,  and,  again,  gummata  of  the 
heart,  stomach,  etc.  Gummy  tumor  of  muscle,  however,  is  usually 
found  in  a  large  muscle,  such  as  the  gluteus,  trapezius,  sterno-mastoid, 
and  pectoralis  major. 

Symptoms. — A  lump  appears  in  the  affected  muscle,  with  no  pain. 
It  is  usually  large  when  discovered,  and  then  continues  to  grow  until 
it  may  reach  the  size  of  an  orange,  and  interfere  greatly  with  the  con- 

*  Op.  dL,  p.  718.  f  These  de  Paris,  ISTQ. 

X  "  Archiv  f.  Path.  Anat.,"  iv,  p.  2vL 


640  SYnilLIS  OF  SPECIAL  TISSUES  AND   ORGANS. 

tractile  function.  The  swelling,  not  very  hard  at  first,  is  found  to  be 
fixed  when  the  muscle  containing  it  is  contracted  ;  movable,  when  it 
is  relaxed  (Xelaton).  If  cut  into  early,  the  appearance  is  as  of  a  gray- 
ish plastic  effusion  around  the  muscular  libers,  which  have  lost  their 
color.  Th6  skin  is  not  discolored  ;  there  may  be  some  pain,  especially 
at  night.  The  tumor  now  sometimes  goes  on  to  grow  rapidly  and  to 
soften.  Perhaps  it  is  opened  as  an  abscess,  or  discharges  spontane- 
ously, in  exceptional  cases,  a  thick,  mucilaginous  mass,  perhaps  slightly 
bloody.  Interstitial  organization  and  absorption  sometimes  take  place, 
leaving  a  hard,  cicatricial  nodule,  perhaps  encysted,  iibrous  in  char- 
acter, possibly  calcified. 

A  muscular  gumma  may  be  alone,  or  may  have  companions.  Usually 
there  are  other  syphilitic  manifestations  present  to  assist  the  diagnosis. 
Section  of  gummy  tumor,  at  its  different  periods,  shows  it  as  a  grayish- 
red,  gelatinous  substance,  or  as  a  yellowish-white,  hard  mass,  looking 
like  the  section  of  cicatrix,  perhaps  calcareous,  or  if  softened  (not 
organized)  it  may  resemble  thick  gum,  or  show  any  of  the  stages  of 
cheesy  degeneration.  Atrophy  of  muscle  from  nervous  disease  due  to 
syphilis  has  been  recorded. 

Treatment  is  that  of  tertiary  syphilis.  Local  measures  are  un- 
necessary. 

SYPHILIS    OF    THE    JOINTS. 

Early  after  infection,  often  with  the  syphilitic  fever,  there  is  com- 
plaint of  pain  in  the  joints,  some  of  which  perhaps  become  congested, 
swell,  contain  an  excess  of  fluid,  and  are  j^ainful  on  movement.  This 
inflammation  is  usually  insignificant,  but  occasionally  intense  enough 
to  pass  for  mild  inflammatory  rheumatism.  It  may  attack  the  joints 
symmetrically.  It  rarely  relapses.  One  form  of  syphilitic  joint-dis- 
ease has  already  been  described  in  connection  with  dactylitis. 

Joint  affections  are  rare  in  syphilis,  but  modern  literature  contains 
a  goodly  number  of  cases.  A  gummy  deposit  in  the  capsule,  outside 
of  the  synovial  membrane,  attended  by  thickening,  which  may  be  felt, 
perhaps  movable  like  a  foreign  body,  and  slow  effusion  into  the  joint, 
are  the  characters  of  syphilitic  synovitis  according  to  Eichet,  who  be- 
lieves that  return  of  the  fluid  after  absorption  is  a  feature  of  diagnostic 
value.  There  is  no  fever,  pain  may  be  absent,  is  usually  nocturnal 
when  present,  and  is  not  aggravated  by  motion.  There  is  little  or  no 
tendency  to  anchylosis.     The  knee-joint  is  the  one  usually  involved. 

Treatment  is  often  brilliantly  effective. 

Serpiginous  ulcerations  around  a  joint  may  be  attended  by  stiffen- 
ing and  some  effusion  into  its  cavity  without  actual  joint-disease. 
Eichet's  second  form  is  articular  ostitis.  This  has  been  observed  in 
the  knee  and  hip.     Here  the  bone,  for  some  distance  from  the  articu- 


SYPHILIS   OF   BONES.  041 

lation,  is  the  seat  of  the  disease.  There  is  severe  pain,  especially  at 
night  and  on  pressure.  'J'hcre  is  great  swelling  and  a  large  amount  of 
effusion.  The  folds  of  the  synovial  membrane  thicken  from  a  gummy 
deposit.  The  cartilages  of  incrustation  become  eroded.  All  the 
fibrous  tissues  around  the  joint  may  become  transformed,  into  a  gelati- 
nous-looking, gummy  material.  False  membrane  may  unite  opposite 
surfaces,  and.  anchylosis  eventually  result,  as  in  one  of  Bumstead's 
cases.  Undoubtedly  this  lesion,  if  allowed,  to  progress,  would  eventu- 
ate in  the  disorganization  of  the  joint,  but  treatment  may  stop  it  at 
any  stage,  as  there  is  no  tendency  to  suppuration.  Kichet's  two  forms 
of  joint  affection,  it  will  be  noticed,  corresj)ond  roughly  with  what  is 
observed  in  the  two  forms  of  joint-disease  as  seen  in  dactylitis. 

Diagnosis. — In  white-swelling  there  is  pain  in  the  joint  early,  the 
brawny  feel  extends  over  the  whole  articulation,  there  are  no  circum- 
scribed hardened  patches.  The  disease  goes  on  to  disorganization. 
The  joint  loses  its  movements  early.  Anchylosis  is  common.  The 
great  elements  of  diagnosis  in  syphilitic  arthropathy  are  the  history  of 
the  case,  the  absence  of  pain,  preservation  of  movement  in  the  joint 
long  after  it  would  have  been  abolished  by  a  similar  amount  of  disease 
from  any  other  cause.     There  may  be  pain,  worse  at  night. 

Treatment  is  that  of  late  syphilis,  with,  locally,  rest  for  the  joint 
and  any  soothing  measures  suggested  by  inflammatory  symptoms. 

SYPHILIS   OF    BONES. 

Symptoms  referable  to  bones  occur  in  secondary  as  well  as  in  ter- 
tiary syphilis.  In  exceptional  cases  even  nodes  have  been  observed 
early,  upon  the  cranium,  before  the  appearance  of  the  earliest  cutane- 
ous manifestations,  and  on  many  of  the  superficial  bones  along  with 
the  earlier  syphilides.  These  phenomena  have  been  chiefly  observed 
and  described  by  Gh.  Mauriac*  They  are  undoubtedly  local  conges- 
tions of  the  periosteum,  with  serous  effusion,  but  probably  not  much 
cell-hyperplasia.  They  always  disappear  in  a  few  weeks,  leaving  no 
trace,  or  nothing  more  than  a  slight  thickening  (in  Mauriac's  thirteen 
cases).  But  even  admitting  all  these  thirteen  cases  to  have  been  relia- 
ble observations,  still  the  rule  would  remain  that  bone-lesions  occur 
late  in  the  evolution  of  the  disease,  exceptions  to  the  contrary  not- 
withstanding. Early  in  the  disease,  often  with  syphilitic  fever,  occur 
pains  of  a  peculiar  variety,  called  osteocopic.  They  may  be  light,  or 
again  furiously  intense.  Sometimes  they  are  absent  altogether.  The 
pains  are  usually  of  a  boring,  splitting  character,  seemingly  seated  in 
the  depth  of  the  bone.  They  may  be  continuous,  but  usually  remit 
by  day  to  commence  again  toward  evening,  or  perhaps  not  until  after 
nightfall.     Sometimes  they  recur  at  the  same  hour  nightly.      They 

*  "  Aff.  Syphilitiques  precoces  du  Systeme  osseux,"  1S72. 
41 


(542  SYPniLIS   OF   SPECIAL   TISSUES   AND   ORGANS. 

usually  cease  at  break  of  day,  or  perhaps  continue  on  for  a  while  into 
the  morning.  AVhen  they  are  continuous,  there  is  almost  invariably 
a  nocturnal  exacerbation,  and  this  character  of  the  pains,  although 
not  exclusively  a  feature  of  syphilitic  bone-pains,  is  nevcrLheless  so 
constant  tliat  the  occurrence  of  pain  in  tiie  bones,  with  nightly  ex- 
acerbations, leads  at  once  to  the  suspicion  of  syphilis  as  a  cause.  These 
pains  are  often  relieved  instead  of  aggravated  by  pressure.  The  seat 
of  the  earlier  osteocopic  pains  is  about  the  joints,  and  in  the  head  and 
neck.  The  shoulders,  elbows,  and  knees  often  suffer  ;  the  continuity 
of  the  long  bones  less  often.  The  pains  may  leave  one  point,  to  pass 
rapidly  to  another.  They  often  cease  when  an  eruption  comes  out,  but 
may  continue  long  afterward.  Usually  there  is  neither  heat  nor*  swell- 
ing at  the  painful  points,  but  in  exceptional  instances  nodes  have  been 
noticed  with  the  earliest  eruptions.  Mercury  has  no  relation  (of  caus- 
ality) to  these  earlier  pains,  which  in  fact  disappear  under  its  use,  and 
are  often  most  severe  in  those  who  have  not  used  the  mineral. 

Positive  lesions  of  bone  due  to  syphilis  occur  late  in  the  disease, 
with  the  late  secondary  eruptions,  or  at  any  time  thereafter.  The  pre- 
vious exhibition  of  mercury  is  in  no  way  responsible  for  their  appear- 
ance, since  they  occur  in  cases  which  have  never  been  treated  with  that 
metal,  and  are  not  encountered  upon  patients  treated  mercurially  for 
other  diseases,  even  salivated.  Any  bone  in  the  body  may  be  affected 
by  syphilis,  but  certain  of  them  suffer  by  preference,  such  as  the  thin 
bones  of  the  nose  and  pharynx,  all  superficial  bones,  especially  such  as 
are  exposed  to  slight  constant  injuries,  bones  of  the  skull,  the  clavicle, 
ulna,  tibia,  ribs.  Several  bones  are  often  simultaneously  involved. 
Usually  other  symptoms  of  syphilis  coexist  with  the  bony  lesions,  but 
not  necessarily.  The  lesion  may  commence  from  without,  an  ulcer  eat- 
ing down,  exposing  the  bone  and  being  followed  by  specific  changes  in 
the  latter.  Ordinarily,  however,  the  changes  commence  from  within. 
No  better  classification  can  be  offered  than  the  one  adopted  by  Lan- 
cereaux  : 

(«)  Inflammatory  osteo-periostitis. 

(b)  Gummy  tumor  of  bone. 

(c)  Dry  caries  (Virchow),  atrophic  form. 

(a)  Inftammatory  Ostco-periostitis. — The  changes  in  tliis  form  com- 
mence under  the  periosteum,  and  in  the  Haversian  canals  of  the  subja- 
cent bone.  The  parts  become  engorged  with  blood.  A  sero-glutinous 
material  next  appears,  which  raises  the  periosteum  into  an  oval  swell- 
ing, shading  off  insensibly  in  all  directions.  This  swelling  is  called  a 
node.  It  may  be  very  small,  or  cover  a  large  area  of  superficial  bone. 
The  skin  moves  over  it,  but  it  is  evidently  fixed  immovably  to  the 
-bone.  It  may  feel  very  tense  and  hard,  but  is  often  doughy,  or  even 
decidedly  fluctuating  at  first.  There  may  be  some  surrounding  oedema. 
Nodes  are  painful  to  pressure,  and  often  the  seat  of  continuous  spon- 


GUMMY   TUMOR   OF   BONE.  643 

taneous  pain,  almost  invariably  worse  at  night.  The  pain  is  aching, 
acute,  throbbing  or  boring  in  character.  Lesions  of  the  skull  often 
give  rise  to  continual  headache.  Growing  from  the  inner  table  of  the 
skull-cap,  a  node  may  occasion  nervous  symptoms,  epilepsy,  paralysis, 
etc.,  or  developing  around  an  emerging  nerve,  neuralgia,  or  local 
paralysis,  or  m  the  spinal  canal  occasion  paraplegia. 

Nodes,  if  treated  early,  promptly  subside,  otherwise  they  increase 
rapidly  in  size,  and  may  soften  centrally.  In  such  cases  the  skin  over 
them  first  becomes  adherent,  then  red  and  oedematous,  finally  gives 
way,  leaving  an  open  characteristic  syphilitic  ulcer,  with  diseased, 
carious,  or  necrosed  bone  at  its  base  (carious  ulcer).  Portions  of  bone 
come  away,  the  ulcer  does  not  extend,  but  finally  cicatrizes,  leaving 
an  adherent,  depressed  scar  surrounded  by  an  hypertrophied  hardened 
ridge  of  bony  tissue  of  new  formation. 

Instead  of  thus  softening,  the  node  may  go  on  to  bony  organization, 
forming  exostosis,  or  leading  to  jDcrmanent  general  thickening  of  the 
normal  bony  tissue  (parenchymatous  exostosis).  Exostoses  once  formed, 
do  not  disappear.  Partial  absorijtion  may  ensue,  but  treatment  fails  to 
remove  the  bony  ridge,  or  interstitial  thickening,  which  remains  be- 
hind, to  serve  as  an  important  landmark  to  the  surgeon  of  the  previous 
visitations  of  the  disease. 

Ejjipliysary  exostosis  is  a  bony  tumor  or  ridge,  which,  forming 
separately,  subsequently  becomes  firmly  attached  to  the  bone.  They 
are  prominent  or  flat,  of  different  sizes  and  shapes,  and  may  be  attached 
to  the  bone  only  by  a  peduncle. 

Diagnosis. — It  is  hardly  possible  to  confound  the  oval,  painful, 
boggy  or  hard  bony  lesion,  known  as  a  node,  accompanied  by  its  noc- 
turnal exacerbations  of  pain,  with  any  other  lesion.  Ostitis  with  paren- 
chymatous thickening  is  less  positive  in  its  characters,  but  the  history 
of  the  case,  nocturnal  pains,  and  concomitant  or  antecedent  syphilitic 
symptoms,  rarely  leave  the  diagnosis  doubtful. 

(h)  Gumimj  Tumor  of  Bone. "^ — Gummy  tumor  develops  either  un- 
der the  periosteum,  in  the  substance  of  the  bone,  or  in  the  medullary 
canal.  It  is  simply  an  intensification  of  the  process  found  in  the  in- 
flammatory form  already  described,  the  difference  being  that  the  cell 
hyperplasia  is  more  luxuriant.  Much  of  the  new  material  (gumma) 
collects  in  a  circumscribed  space,  and,  being  more  rapidly  formed  and 
less  capable  of  organization,  it  entails  more  profound  lesions  by  its  ret- 
rograde metamorphosis.  Gummy  tumor  of  bone  is  therefore  a  much 
more  serious  and  inveterate  form  of  disease  than  syphilitic  osteo-peri- 
ostitis. 

Gummy  tumors  of  the  periosteum  are  circumscribed  swellings  with 
a  fixed  base,  usually  soft  and  fluctuating,  containing  a  yellowish-white, 

*  A  syphilitic  angular  curvature  of  the  spine,  due  to  gumma  of  the  vertcbrEe,  has  been 
reported  by  Fournier,  "Ann.  de  Derm,  et  de  Syph.,"  11,  i,  1881,  p.  19. 


644  SYPHILIS   OF   SrEClAL   TISSUES   AND   ORGANS. 

thick  material,  resembling  a  solution  of  gum-arabic.  Like  gummv 
tumors  elsewhere,  they  tend  to  soften,  the  skin  reddens,  intlanies,  ul- 
cerates, and  the  broken-down  gummy  material  escapes,  leaving  behind 
an  ulcer  with  diseased  (necrosed)  bone  at  its  base.  Sometimes  gummy 
tumor  becomes  incrusted  with  calcareous  salts,  and  remains  as  a  i)erma- 
nent  swelling,  a  sort  of  exostosis. 

Interstitial  gummy  tumor  acts  dilTercntly  in  the  long  and  in  the  flat 
bones.  In  the  long  bones  the  medullary  canal  is  usually  the  seat  of 
deposit,  which  continues  through  the  bony  tissue.  The  bone  becomes 
hypertrophied  in  a  porous  manner,  the  Haversian  canals  and  canali- 
cules  being  enlarged  and  filled  with  gummy  deposit,  eitlier  fresh  and 
gelatinous,  or  in  different  stages  of  degeneration,  yellow,  white,  cheesy, 
and  pultaccous.  Thus  a  portion,  or  the  whole  thickness  of  the  bone, 
may  enlarge.  In  the  flat  bones,  such  as  especially  the  cranial  bones, 
the  cancellar  tissue  is  attacked  (the  diploe),  where  gummy  material 
collects  in  greater  or  less  abundance,  separating  the  two  tables  of  the 
skull,  and  eventually  often  involving  one  or  the  other  of  them  in  ne- 
crosis, or  in  caries.  Gummy  tumors  of  bone  are  often  exceedingly 
painful,  especially  during  the  nocturnal  exacerbation.  Although  ab- 
sorption may  take  place,  or  calcification,  or  ossification,  yet  there  is  a 
certain  marked  tendency  to  rapid  softening  of  the  deposit,  and  conse- 
quent caries,  or,  more  often,  a  cutting  off  of  a  portion  of  the  cortical 
layer  of  a  bone  by  the  softening  of  a  deposit  of  gummy  material,  which 
underlies  and  has  infiltrated  it.  By  the  coalition  of  many  distinct 
foci  great  destruction  of  tissue  may  result,  large  portions  of  the  skull- 
cap, the  whole  frontal  bone  (either  table  or  both),  large  jjortions  of  the 
sides  or  back  of  the  skull,  may  necrose  and  come  away,  or  be  removed, 
leaving  the  dura  mater  exjiosed.  In  connection  with  necrosis  of  the 
inner  table,  and  accumulation  of  softened  gummy  matter  in  contact 
with  the  dura  mater,  brain-symptoms  may  occur.  Such  necroses  are 
common  on  the  skull,  and  not  very  rare  on  the  other  superficial  bones, 
tibia,  ribs.  A  syphilitic  sequestrum  is  usually  worm-eaten,  and  per- 
forated by  many  holes,  where  the  gummy  material  in  its  deposit  has 
encroached  upon  or  perforated  the  portion  which  is  thrown  off,  instead 
of  being  smooth  on  its  external  surface,  as  would  be  a  sequestrum  from 
other  cause.  Synchronously  with  the  separation  of  the  sequestrum, 
the  edges  of  the  bone  at  and  beyond  the  line  of  demarkation  become 
thickened,  elevated,  eburnated,  so  that  after  the  healing  of  the  ulcer 
a  characteristic  cicatrix  is  left,  with  the  skin  adherent,  edges  hard  and 
raised  by  an  excess  of  bone,  centrally  depressed,  and  filled  by  fibrous 
cicatricial  tissue. 

(c)  Dry  caries  has  been  well  known  since  the  publication  of  Vir- 
chow's  accurate  investigations  upon  it.  Virchow  believes  dry  caries  to 
be  occasioned  only  by  syphilis.  The  affection  is  rarely  found  else- 
where than  upon  the  cranial  bones.     Either  or  both  tables  may  suffer. 


SYPHILIS   OF   CARTILAGE.  045 

The  frontal  and  parietal  bones  are  most  often  involved.  The  affection 
is,  indeed,  a  miniature  gummy  ostitis.  Around  one  of  the  vascular 
canals  of  cither  table  of  the  skull  gummy  matter  is  deposited  at  the 
expense  of  bony  material.  The  same  change  occurs  in  the  lateral  vas- 
cular canals  leading  to  the  vertical  canal.  The  gummy  material  is 
finally  absorbed,  leaving  a  stellate  indentation.  This  goes  on  until  a 
funnel-shaped  depression  is  formed,  its  point  leading  into  the  diploe. 
If,  now,  the  points  of  two  such  funnel-shaped  cavities  coincide,  the 
cranial  bone  may  be  perforated.  While  this  atrophic  process  is  going 
on  centrally,  new  bone  is  being  formed  peripherally,  both  on  the  sur- 
face and  in  the  diploe  ;  thus  eburnation  of  all  the  surrounding  tissue 
occurs,  with  hyperostosis  superficially.  In  fact,  each  worm-eaten,  de- 
pressed, funnel-shaped  spot  of  caries  sicca  is  a  miniature  syphilitic 
bone-scar.  The  feature  of  caries  sicca,  however,  is  that  in  it  there  is 
never  any  sequestrum,  any  formation  of  pus,  or  any  implication  of 
the  skin.  The  symptoms  of  its  existence  are  local  pain,  without 
swelling.  The  cicatrices  (of  bone)  left  behind  are  pathognomonic  of 
syphilis.  They  may  be  plainly  appreciated  through  the  scalp  by  the 
finger. 

Treatment  is  that  of  late  syphilis. 

A  syjshilitic  osteo-myelitis  has  been  recorded,  leading  sometimes  to 
osteo-porosis,  and  in  this  way  to  spontaneous  fracture,  or  easy  fracture 
of  bone  (Taylor). 

SYPHILIS   OF   CABTILAGE. 

The  cartilages  affected  by  syphilis  are  only  those  which  are  sur- 
rounded by  perichondrium.  Cartilage  of  incrustation  may  become 
eroded,  but  only  in  connection  with  neighboring  gummy  deposit,  either 
in  the  fibrous  capsule  of  the  Joint,  or  in  the  articular  ends  of  the  bone. 
Tertiary  disease  of  the  larynx  commences  as  a  gummy  perichondritis, 
or  possibly  as  a  muscular  gummy  tumor,  involving  the  cartilage  sec- 
ondarily ,  so  of  the  cartilages  of  the  nose.  Lancereaux  gives  a  case  of 
laryngeal  perichondritis  leading  to  necrosis  of  cartilage,  local  gan- 
grene, and  (the  accident)  subsequent  fatal  j)y£emia.  Syphilis  of  the 
larynx  will  be  described  with  the  air-passages.  Gummy  tumor  some- 
times develops  upon  the  costal  cartilages,  leading  to  necrosis.  These 
gummata  tend  to  soften,  and  behave  exactly  like  similar  formations 
originating  under  the  periosteum  of  sujierficial  bones.  I  have  seen  a 
portion  of  the  cartilage  of  the  ear  eaten  away  by  a  gummatous  ulcer. 

Treatment  is  that  of  late  syphilis. 

SYPHILIS   OF    LYMPHATIC    GLANDS. 

Besides  the  indolent  glandular  enlargements  encountered  in  sec- 
ondary syphilis,  and  already  alluded  to  at  length  (p.  548  et  seq.),  oc- 


04G  SYPHILIS   OF  SPECIAL   TISSUES   AND   ORGANS. 

casionally  these  glands  become  the  seat  of  gummy  deposit  in  tertiary 
disease,  especially  in  strumous  youug  subjects.  Under  these  circum- 
stances thoy  enlarge  painlessly,  soften,  break  down,  and  discharge, 
leaving  a  chronic,  atonic,  gummy  ulcer,  which  is  usually  regarded  as 
"  strumous,"  and  is  very  slow  to  get  well.  These  ulcers  look  like 
chancroids.  They  have,  however,  hard,  adherent  edges,  and  a  gummy, 
false  membranous  bottom.  They  occur  chieily  about  the  neck.  Such 
lesions  leave  puckered,  ridged,  adherent  cicatrices,  usually  with  an 
areola  of  pigment  around  them  ;  possessing,  in  short,  the  characteris- 
tics of  the  strumous  as  well  as  of  the  syphilitic  scar. 

Thickening  of  the  lymi)hatic  trunks  in  a  manner  similar  to  that 
observed  in  syphilitic  arteritis  is  believed  to  occur.* 

The  deep  lymphatic  glands  suffer  habitually  in  connection  with  vis- 
ceral syphilis,  but  these  never  suppurate.  They  may  be  atfccted  alone, 
the  viscera  escajjing.  Either  interstitial  adenitis  takes  jolace  at  the 
expense  of  the  connective-tissue  parenchyma,  by  which  the  gland-cells 
become  pressed  upon  and  atrophied,  and  finally,  by  shrinkage  of  the 
new-formed  connective  tissue,  the  whole  gland  becomes  sclerosed,  con- 
tracted, and  seemingly  composed  entirely  of  connective  tissue,  or  a 
quick  proliferation  of  cells  takes  place,  incapable  of  organizing  (gummy 
material),  the  gland  becomes  plump  and  large,  at  first  firm,  then  soft, 
as  the  gummy  material  softens,  undergoing  its  retrogressive  changes. 
Finally,  a  mass  of  cheesy  degeneration  alone  is  left,  perhaps  calcified. 
According  to  Lancereaux,  the  glands  are  often  found  increased  in  size 
in  their  long  diameter,  mainly  of  reddish  color,  soft  and  of  brittle  con- 
sistence, more  or  less  cheesy.  The  deep  ganglia  most  commonly 
affected  are  the  prevertebral,  lumbar,  iliac,  and  femoral ;  next  the 
bronchial  and  mediastinal.  The  mesenteric  glands  rarely  suffer,  least 
often  the  glands  of  the  extremities. 

These  deep  glandular  alterations  sometimes  exist  without  symp- 
toms, but  symptoms  may  be  caused  by  them  in  two  ways  :  First, 
mechanically,  by  interfering  with  function  (the  discharge  of  bile,  thus 
occasioning  icterus)  ;  second,  in  all  probability,  by  interfering  with 
blood-elaboration,  thus  holding  a  large  share  in  the  production  of 
cachexia. 

SYPHILIS    OF    THE    MAMMARY    GLAND. 

Mucous  patches,  chancre,  all  the  cutaneous  lesions,  appear  upon 
the  breast,  but  the  mammary  gland  itself  may  also  be  involved  in 
syphilis.  Syphilis  attacks  the  mamma  in  the  same  two  ways  in  which 
it  affects  all  glands  : 

(1)  As  a  diffuse  interstitial  parenchymatous  inflammation. 

(2)  As  distinct  gummy  tumor. 

*  J.  Hutchinson,  "Lancet,"  Feb.  10,  1877,  p.  199. 


SYPHILIS   OF  THE   MAMMARY   GLAND.  647 

(1)  Diffuse  ^ypldUtic  mastitis  is  observed  in  both  sexes.  Ambro- 
soli  *  reports  three  cases  ;  one  in  a  male,  the  others  in  females.  The 
gland  swells,  becomes  slightly  painful  and  tense.  The  skin  remains 
unchanged.  No  separate  tumor  is  formed.  All  tlie  cases  olxserved 
have  occurred  during  the  secondary  j^criod  shortly  after  cutaneous 
eruptions.  A  few  indolent  ganglia  may  be  found  in  the  axilla.  The 
affection  disappears  without  leaving  any  trace. 

(2)  Gummy  Mastitis. — Eichet  f  mentions  a  tumor  of  the  breast 
which  he  believed  to  be  scirrhous.  He  prepared  to  extirpate  it,  but, 
finding  by  accident  a  tumor  in  the  patient's  calf,  he  paused,  reflected, 
administered  the  iodide  of  potassium,  and  both  tumors  disappeared. 
Gummy  tumor  is  rare  in  the  breast,  and  when  found  there  usually  co- 
exists with  gummy  tumors  or  ulcers  elsewhere.  It  forms  with  little 
or  no  pain,  may  attain  a  large  size,  and  then  degenerates  and  dis- 
charges externally  (when  it  is  liable  to  be  mistaken  for  cancer),  or  is 
aborted.  Mastitis  is  usually  bilateral.  The  course  of  the  disease  and 
its  attendant  specific  history  serve  to  distinguish  it  from  other  benign 
or  cancerous  mammary  enlargements. 


CHAPTER  XI. 

VISCERAL  SYPHILIS. 


Syphilis  of  the  Vascular  System. — Syphilis  of  the  Respiratory  System. — Syphilis  of  the  Digestive 
System,  including  the  Tongue  and  the  Great  Abdominal  Glands.— Syphilis  of  the  Peritonaeum, 
Thyroid,  and  Thymus.— SyphUis  of  the  Genito-Urinary  System. 

Syphilis  of  the  Vascular  Ststeit. — Of  the  circulatory  organs, 
the  heart  most  frequently  suffers,  the  arteries  next,  while  no  authentic 
case  of  syphilitic  lesion  originating  in  the  veins  has  been  reported. 

Syphilitic  Pericaeditis  has  been  very  rarely  observed.  Wilks, 
Virchow,  Lancereaux,  and  Wagner,  have  seen  it.  The  affection  is 
tertiary,  and  is  either  a  diffuse  pericardial  infiltration  or  a  circum- 
scribed gummy  tumor.  It  rarely  occurs  except  in  connection  with 
specific  myocarditis.  It  does  not  seem  to  occasion  any  considerable 
febrile  or  other  disturbance,  and  the  diagnosis  is  usually  made  after 
death. 

Myocarditis  due  to  syphilis  is  either  diffuse  or  circumscribed 
(gummy  tumor).  The  two  forms  may  occur  separately,  but  usually 
coincide.  The  diffuse  form  consists  in  cell-proliferation,  attended  by 
hypersemia  and  formation  of  new  connective  tissue,  then  destructive 
metamorphosis  with  absorption,     A  yellowish  coloration  in  patches  is 

"  Quoted  by  Lancereaux. 

f  "Traite  d'Anatomie  Medico-Chirurgicale,"  fourth  edition,  ISTS,  p.  330. 


648  VISCERAL  SYPHILIS. 

produced  by  tlic  fatty  changes  in  tlie  new  grovctli  ;  finally,  portions  of 
the  muscnlar  tissue  disappear  by  absorption. 

In  the  gummy  form  circumscribed  tumors  of  small  size  appear, 
preferably  in  the  ventricles  where  the  muscular  wall  is  thickest.  The 
surrounding  tissue  is  the  seat  of  diffuse  myocarditis  ;  the  walls  of  the 
heart  thicken  ;  its  cavities  enlarge  ;  its  muscular  ]io\ver  is  impaired. 
The  valves  usually  escape — a  sign  of  diagnostic  imj)ortancc.  The 
endocardium  and  pericardium  may  both  be  involved.  These  heart- 
lesions  are  rarely  detected  during  life.  Lancereaux  diagnosticated  a 
case  which  got  well  under  the  use  of  iodide  of  potassium.  The  course 
of  the  disease  is  long,  its  beginning  insidious.  The  possibility  of  ul- 
ceration of  a  gumma  into  one  of  the  heart-cavities,  and  subsequent 
embolic  obstruction  of  vessels  at  a  distance,  has  been  pointed  out  by 
Lancereaux.*  Grenouiller.f  drawing  deductions  from  twenty-four  col- 
lated cases,  believes  that  myocarditis,  commencing  as  a  small  gumma 
and  ending  in  fibrous  sclerosis,  is  the  commoner  form,  dilfnse  intersti- 
tial myocarditis  less  usual.  Gumma  was  found  in  eighteen  of  the 
twenty-four  cases  once  in  the  first  year,  but  averaging  ten  years  after 
infection.  The  left  ventricular  wall  was  its  most  common  scat.  There 
are  no  positive  pathognomonic  symptoms  during  life  by  which  this 
malady  may  be  detected.  Heart-disease  was  sometimes  suspected. 
About  two  thirds  of  the  cases  terminated  in  sudden  death.  S. 
Smith  I  reports  gumma  of  heart  in  left  ventricle  of  an  apparently 
healthy  woman,  leading  to  sudden  death.     Teisser  *  has  a  recent  case. 

Si/mpto7ns  are  :  increase  of  size  in  the  heart,  eufeeblement  and 
irregularity  of  its  action,  palpitation,  finally  asystole  ;  sometimes  pros- 
cordial  pain  and  distress,  a  little  dyspnoea,  some  turgescence  of  the 
vessels  of  the  neck,  sometimes  slight  oedema  of  the  lower  extremities, 
rarely  any  valvular  murmur. 

Diagnosis. — A  syphilitic  history,  the  coincidence  of  other  tertiary 
phenomena,  the  usual  absence  of  evidence  of  valvular  lesion,  are  the 
main  features  of  a  differential  diagnosis.  Sudden  death  is  the  most 
common  termination,  but,  if  treatment  be  commenced  before  the 
muscular  tissue  of  the  heart  has  been  materially  altered,  there  is  every 
reason  to  believe  that  a  cure  may  be  effected. 

Treatment  is  that  of  late  syphilis. 

Lancereaux  believes  there  may  be  an  amyloid  change  in  the  mus- 
cular structure  of  the  heart. 

Syphilitic  Arteritis. — Heubner's  ||  admirable  monograph  first  se- 
riously aroused  the  profession  to  the  importance  and  extent  of  the 

*  "Archiv.  G6n.,"  July,  1873. 

f  "Cardiac  Syphilis,"  TbJsse  de  Paris,  1878. 

X  Syphiloma  of  heart,  "Lancet,"  February  16,  1878,  p.  240. 

*  "Ann.  de  Derm,  et  de  Syph.,"  second  ser.,  t.  iii,  No.  6. 

D  "Die  lenetische  Erkrankung  der  Ilirnartcrien,"  Leipsic,  1874. 


SYPHILITIC   ARTERITIS.  649 

possible  changes  in  the  smaller  arteries  which  might  he  duo  to  syphilis. 
Before  this  Weber,  Virchow,  Lancereaux,  and  a  few  others  appreciated 
the  grosser  changes  inflicted  upon  the  larger  arteries  by  syphilis,  the 
tendency  to  atheroma  produced  by  the  disease,  and  the  not  uncommon 
appearance  of  aneurism  upon  one  of  the  larger  vessels  as  a  result  of 
syphilis.  But  it  is  only  since  Ileubner  that  our  knowledge  of  the  act- 
uality of  syphilitic  arteritis  has  been  at  all  developed.  The  large  and 
small  arteries  may  suffer  together  or  separately,  but  the  special  arteri- 
tis described  by  Heubner  is  best  seen  in  the  arteries  at  the  base  of  the 
brain.  The  smaller  vessels  of  other  internal  organs  besides  the  brain 
also  suffer.  The  arterial  change  consists  in  a  thickening  of  the  coats 
of  the  vessel  for  a  portion  of  its  course,  so  that  the  vessel  becomes 
more  cord-like  and  its  lumen  becomes  measurably  diminished  up  to 
the  point  of  entire  occlusion.  The  change  may  not  surround  the  ves- 
sel, but  only  appear  as  hardened  masses  in  the  wall.  Thrombi  may 
form  at  the  narrowed  portions.  An  aneurismal  dilatation  of  the  ves- 
sel-wall may  be  found  near  the  point  of  thickening.  The  ultimate 
termination  of  the  vascular  change  is  fibrous  degeneration  and  occlu- 
sion of  the  tube.  The  histological  changes  are  cell-proliferations  in 
the  intima  and  adventitia,  extending  thence  to  the  muscular  coat. 
The  stiffened  walls  of  the  smaller  vessels  may  split  and  allow  hemor- 
rhage, instead  of  dilating  into  aneurismal  pouches. 

The  walls  of  the  larger  arterial  vessels  are  subject  to  gummy  infil- 
trations, either  diffused  between  the  coats  of  the  artery  for  some  length, 
thickening  the  same  and  thus  decreasing  the  caliber  of  the  vessel,  or 
developing  as  a  distinct  tumor  in  the  vessel-wall.  Both  forms  have 
been  observed.  In  the  larger  vessels  fatty  metamorphosis  of  the  new 
tissue  occurs,  with  calcification  leading  to  atheromatous  patches  ;  in. 
the  smaller  vessels  obliteration  of  the  caliber  may  ensue.  Aneurism 
may  owe  its  origin  to  the  weakening  and  softening  of  the  arterial  wall 
by  degeneration  of  gummy  deposit,  or  the  vessel  may  give  way,  allow- 
ing an  apoplexy  to  occur.  Any  artery  may  .suffer,  but  the  carotids 
and  arteries  of  the  brain  most  commonly.  An  accurate  diagnosis  of 
these  lesions  has  usually  been  made  after  death,  as  no  symptoms  during 
life  are  pathognomonic  of  their  existence.  They  are  a  not  very  infre- 
quent cause  of  brain-symptoms,  by  cutting  off  the  supply  of  blood. 
Their  presence  may  be  inferred  in  many  cases  of  aneurism  in  patients 
with  old  syphilis. 

Syphilis  of  the  veins  has  not  been  thoroughly  worked  out.  Huber  * 
describes  a  general  condition  of  thickening  and  calcification  along  the 
larger  veins  of  the  lower  extremities,  with  changes  in  many  of  the 
other  arteries  and  veins  in  the  body,  which  he  believed  to  be  syphilitic. 
J.  Hutchinson  f  believes  that  inflammatory  conditions  about  varices 

*  Virchow's  "  Archiv,"  Heft  III,  1880,  p.  53V. 
f  "  Lancet,"  Feb.  10,  1877,  p.  199. 


650  VISCERAL  SYrniLis. 

and  healthy  veius  may  be  sypliilitic.  The  umbilical  vein  in  the  syphi- 
litic faHiis  (Mervis,*  Birch  llirschl'eld.f  Oedmaiisson  J)  has  been  found 
contracted  in  its  lumen  with  a  proliferation  of  cells  in  the  inner  coat 
similar  to  that  found  in  the  arteries.  The  portal  vein  has  been  found 
aifected  in  the  case  of  syphilitic  children  by  Schiippel.* 

The  ca])illaries  have  in  their  external  tunic  the  point  of  origin  of 
the  gumm;i,  and  fatty  degeneration  of  their  walls  has  been  observed 
(Laucereaux). 

The  arterial  changes  occur  in  inherited  as  well  as  in  ac(]uircd  syphi- 
lis. They  usually  come  on  late,  sometimes  many  years  after  infection, 
but  they  may  occur  early.  Sharkey  showed  to  the  London  Pathologi- 
cal Society,  January  16,  1883,  microscopic  sections  from  syphilitic  ar- 
teritis of  the  brain  from  a  man  who  died  seven  months  from  the  date 
of  infection. 

SYPHILIS    OF    THE    RESPIRATOHY   SYSTEM. 

The  affections  due  to  syphilis  occurring  upon  the  skin  and  mucous 
membrane  of  the  nose  have  been  already  described  (Chapters  VI  and 
VII).  The  bones  about  the  bridge  of  the  nose  are  very  apt  to  be  de- 
stroyed by  tertiary  syphilis,  and  discharged  either  through  the  nostrils 
or  by  ulceration  of  the  skin  over  them.  These  destructions  of  bone  are 
not  replaced,  and  recovery  involves  a  sunken  bridge. 

Sypuilis  of  the  Laryxx. — The  erythema  and  mucous  patches  of 
the  larynx,  sometimes  found  in  secondary  syphilis,  have  been  described 
(p.  595  et  seq. ).  Tertiary  changes  remain  to  be  observed.  There  are 
two  varieties,  and  they  occur  in  inherited  as  well  as  acquired  disease  : 

1.  Diffuse  nou-ulcerative  laryngitis. 

2.  Ulcerative  laryngitis 

1.  The  diffuse  non-tdccrative  form  is  rare.  It  consists  in  chronic 
diffuse  connective-tissue  hyperplasia  resulting  in  general  thickening  of 
the  A^ocal  cords  and  surrounding  tissues,  without  deep  or  destructive 
ulceration.  The  voice  becomes  first  hoarse,  then  reduced  to  a  whisper, 
perhaps,  finally,  after  many  months,  nearly  lost ;  and  difficulty  of 
breathing  comes  on,  gi'adually  progressing  with  the  thickening  of  the 
laryngeal  tissue,  until  suffocation  becomes  imminent.  Little  or  no 
pain  is  experienced.  Pressure  over  the  larynx  is  somcAvhat  painfnl. 
The  affection  progresses  slowly.  Dj'spnoea  is  the  main  symj^tom,  with 
modification  of  voice,  and,  in  the  later  stages,  emaciation,  sleejaless- 
ness,  cachexia,  with  more  or  less  cyanosis,  and  a  quick,  labored  action 
of  the  heart.  The  lungs  remain  healthy.  The  laryngoscope  shows  a 
dark-colored  mucous  membrane  in  the  larynx,  a  general  thickening  of 

*  "Ztschrift.  f.  Gbrtshlfe.  u.  Gynklgic,"  1879,  p.  48. 
■f  "Wiener  med.  Wchnschrft,"  1875,  p.  555. 
X  Referred  to  in  "  Archiv  f.  Gynaekologie,"  1870,  p.  523. 
»  "  Archiv  der  Ileilkunde,"  1870,  p  74. 


SYPHILIS   OF   THE   LARYNX.  051 

tissues,  with  more  or  less  oodema  and  restriction  in  the  movements  of 
the  vocal  cords,  but  no  ulceration.  (Edema  of  the  glottis  may  come 
on,  rapidly  inducing  alarming  symptoms  of  suffocation. 

Diagnosis. — A  history  of  syphilis,  and  the  absence  of  tubercular 
disease  in  the  lung,  make  the  diagnosis  between  this  affection  and  tu- 
bercular chronic  laryngitis  easy.  Treatment  is  effective  in  the  earlier 
stages,  but  not  always  curative  in  old  cases  where  new-formed  and  con- 
tracted connective  tissue  has  glued  the  parts  together.  Tracheotomy 
in  these  cases  is  the  main  resource.  It  may  be  necessary  to  wear  a  tube 
permanently. 

2.  Gummy  Ulcerative  Laryngitis. — This  is  not  a  very  uncommon 
affection  in  the  tertiary  stage  of  severe  or  badly-managed  cases.  It 
comes  on  as  an  ulcer  of  the  mucous  membrane,  secondarily  affecting 
the  perichondrium  and  the  cartilage,  or  begins  under  the  perichon- 
drium, or  possibly  as  a  neighboring  gummy  tumor.  The  ulcer  may 
involve  the  posterior  surface  of  the  epiglottis,  and  indeed  be  continuous 
with  serpiginous  gummy  ulceration  of  the  pharynx.  The  gummy  ma- 
terial under  the  perichondrium  usually  softens  and  ulcerates  its  way 
out  as  it  does  when  forming  near  bone,  and  may  be  attended  by  necro- 
sis of  more  or  less  of  the  cartilages  of  the  larynx.  The  laryngoscope 
shows  perhaps  non-ulcerated  prominences,  usually  ragged  ulcers  with 
considerable  surrounding  oedema ;  these  appearances  sometimes  ex- 
tending through  the  larynx  into  the  trachea.  White  contracted  cica- 
trices of  older  ulcers,  which  have  healed,  may  also  be  seen.  The  rima 
glottidis  may  be  nearly  occluded  (Elsberg).* 

The  symjjtoms  of  this  affection  are  hoarseness,  perhaps  a  whisper- 
ing voice,  possibly  total  loss  of  voice,  slight  laryngeal  jiain  at  times, 
cough,  at  first  dry,  then  with  bloody,  purulent  expectoration  or  por- 
tions of  slough  ;  oedema  of  the  glottis  sometimes  occurs,  but,  in  any 
case,  respiration  becomes  eventually  seriously  imiDcded.  Dyspnoea  often 
occurs  in  paroxysms.  A  jDortion  of  necrosed  cartilage  may  separate 
and  be  coughed  up  or  drawn  down  into  the  lungs.  The  larynx  is  pain- 
ful to  pressure,  sometimes  visibly  enlarged.  Gummy  deposit  may  form 
in  the  surrounding  tissues,  and  soften.  Emaciation  and  exhaustion 
come  on,  and  life  is  endangered  if  the  disease  be  not  stayed.  After 
the  healing  of  the  ulcers  permanent  trouble  may  be  left  in  the  larynx 
by  contraction  of  the  cicatrices.  During  this  23eriod  the  larpix  may 
be  found  permanently  depressed  and  immovable,  during  deglutition 
and  attemi^ts  at  speech  (Demarquay). 

Diagnosis. — The  history  of  the  ease,  the  frequent  coincidence  of 
present  or  old  (cicatrized)  pharyngeal  ulceration,  and  the  usual  ab- 
sence of  pulmonary  lesions,  distinguish  this  affection  from  phthisical 
laryngitis. 

*  Norton  showed  the  Pathological  Society  such  a  gumma,  as  large  as  an  egg,  "  Path. 
Trans.,"  1874,  p.  38. 


652  VISCERAL  SYPUILIS. 

Gumma  of  the  larynx  may  appear  imlependently  of  suiTOunding 
infiltration  or  ulceration,  and  these  may  retroizrade  into  iibroid  nodules 
or  soften  and  ulcerate,  or  be  absorbed  under  treatment. 

Stenosis  of  the  larynx  may  occur  from  hyperplastic  exudation,  or 
more  commonly  from  cicatrization  after  ulceration,  and  anchylosis  of 
the  crico-arytenoid  articulations  has  been  reported  and  laryngeal  pa- 
ralysis from  lesions  of  nerve  or  brain.  All  tbese  clianges  have  been 
observed  in  inherited  as  well  as  in  ae(|uired  disease. 

Similar  changes  to  those  already  described  for  the  larynx  are  also 
caused  (less  frequently)  by  syphilis  in  the  trachea  and  bronchial  tubes, 
leading  often  by  their  cicatrization  to  permanent  stricture,  which,  if 
extensive,  seriousl}',  perhaps  fatally,  impedes  respiration,  as  cicatrices 
are,  of  course,  not  influenced  by  treatment.  Hence  the  importance  of 
an  early  recognition,  and  a  vigorous  treatment  of  all  tertiary  affections 
of  the  air-passages,  so  as  to  jirevent  extensive  ulceration  and  subsequent 
stricture. 

Sijpliihs  of  the  Lungs. — In  tertiary  and  in  inherited  syphilis  the 
lungs  may  be  alfected  either  by  diffuse  interstitial  chronic  inflamma- 
tion (pneumonia),  or  by  gummy  tumor,  or  both  together.  Eare  in 
the  adult,  these  changes,  especially  the  diffuse  form,  are  common  in 
the  infant  with  inherited  disease.  Early  bronchial  catarrhal  changes 
have  been  noted  by  some  authors  in  secondary  syphilid. 

1.  Chronic  Si/philific  Pneumonia. — This  affection  may  invade  any 
portion  of  the  lung-tissue.  It  consists  in  a  proliferation  of  cells,  and 
a  new  formation  of  connective  tissue  in  the  parenchyma  of  the  lung, 
by  means  of  which  the  air-vesicles  become  decreased  in  size,  or  even 
obliterated,  and  the  portions  involved,  firm,  hard,  non-crepitant,  elas- 
tic. The  affected  spot  is  depressed,  from  contraction  of  the  newly- 
formed  tissue  ;  it  may  be  sprinkled  with  numerous  yellow  points,  seen 
on  section.  An  entire  lobe  is  rarely  involved  all  at  once.  There  may 
be  several  spots  in  the  same  lung.  The  bronchial  tubes  terminating 
in  the  diseased  areas  are  dilated  or  contracted,  sometimes  ending  in  a 
cul-de-sac,  their  walls  yellow,  thickened,  opaque. 

In  the  child  with  inherited  syphilis  the  whole  of  both  lungs  may 
be  involved  by  changes  due  to  interstitial  disease.  These  organs  are 
found  large,  dense,  fleshy,  heavy,  discolored.  They  often  show  prints 
of  the  ribs.  Their  surface  is  smooth  and  marbled.  They  sink  in 
water.  There  may  be  jiartial  emphysema  where  the  air  has  penetrated. 
The  inter-alveolar  tissue  is  thickened,  in  some  portions  more  than  in 
others.     The  bronchial  ganglia  are  enlarged. 

2.  Oummy  Tumors  of  the  Limgs. — These  may  be  single  or  mul- 
tiple. They  are  found  as  yellowish-white  tumors  of  varying  size, 
rarely  larger  than  a  marble,  firm  and  elastic  at  first,  then  softening, 
perhaps  breaking  down.  They  become  surrounded  by  an  indurated 
connective-tissue  wall  (encysted).     Small  vessels  pass  into  these  masses 


GUMMY  TUMORS  OF  THE  LUNGS.  053 

at  first,  but  subsoquontly  become  obliterated.  Tlic.se  tumors  undergo 
the  same  retrogressive  transformatious  as  those  which  alTect  gummy 
material  everywhere — central  softening,  cheesy  degeneration,  absoii)- 
tion — a  cheesy  nodule,  perhaps  calcified,  being  left  behind,  or  rapid 
softening  with  ulceration  of  surrounding  tissue  and  evacuation  of  the 
tumor,  usually  into  a  bronchus,  followed  by  a  cavity  which  cicatrizes, 
leaving  a  stellate  depressed  scar.  Gummy  circumscribed  masses  in 
the  lung  are  less  frequent  in  the  infant  with  inherited  syphilis  than 
the  difl:use  form,  but  they  have  been  occasionally  found,  sometimes  as 
yellowish,  elastic  masses,  sometimes  with  commencing  central  soften- 
ing. The  child  rarely  lives  long  enough  to  allow  them  to  ulcerate 
out. 

Pleural  adhesions,  cicatrices,  and  small  gummy  tumors  coexist  with 
syphilitic  lung-disease. 

Symptoms. — This  malady  comes  on  insidiously  without  fever, 
cough,  or  pain.  The  larynx  is  likely  to  be  involved  at  the  same  time, 
and  its  symptoms  may  be  the  only  ones  noticed.  Physical  signs  are 
only  those  of  feeble  respiration.  Later  there  is  moderate  dry  cough, 
in  some  instances  no  haemoptysis,  in  others  blood  is  often  mingled 
with  the  expectorated  matters  in  small  quantities  at  a  time.  Profuse 
ha3moptysis  is  exceptionally  uncommon.  Finally,  as  the  malady  pro- 
gresses dyspnoea  comes  on,  and  the  physical  signs  of  phthisis,  especially 
if  a  gummatous  focus  has  broken  down.  Occasionally  the  cough  is 
paroxysmal  and  severe.  I  have  known  a  patient  to  cough  nearly  to 
exhaustion,  and  still  have  no  fever,  continue  his  work  as  a  porter,  and 
get  perfectly  well  under  treatment.  The  patient  emaciates,  and  finally, 
if  the  disease  is  unchecked,  has  hectic,  night-sweats,  and  dies  very 
much  as  phthisical  patients  die.  The  course  of  the  disease  is  very 
slow,  extending  sometimes  over  several  years. 

Diagnosis. — Syphilitic  lung-affections  with  or  without  cavity  may 
be  diagnosticated  from  chronic  phthisical  pneumonia  by  the  history, 
concomitant  changes,  the  fact  that  syphilitic  disease  is  not  specially 
prone  to  attack  the  apices  of  the  lungs.  Indeed,  it  elects  the  middle 
lobe,  some  observers  think  the  right  side  by  preference  (Schnitzler, 
Grandidier).  It  is  frequently  unilateral,  the  larynx  is  commonly  also 
involved,  and  its  inspection  with  the  laryngoscope  is  of  great  value  in 
confirming  the  diagnosis.  Finally,  treatment  aflarms  a  correct  diag- 
nosis by  curing  the  patient. 

Treatment  is  mixed,  with  iodides  pushed  according  to  the  patient's 
capacity.  If  the  patient  is  also  phthisical  there  is  more  especial  need 
of  cod-liver  oil,  tonics,  change  of  air,  etc.,  but  these  remedies  are  also 
useful  in  any  case  of  syphilitic  lung-disease. 


654  VISCERAL  sYrniLis. 

SYPHHilS  OP  THE  DIGESTIVE  AND  ABDOMINAIi  ORGANS. 

Erythema,  mucous  and  scaly  patches,  and  ulcerations  of  the  mouth 
and  pliarynx,  have  been  considered  (Chapters  VI  and  VII).  Some- 
thing of  special  description  is  due  to  tertiary  lesions  of  the  tongue, 
since  some  of  them  are  liable  to  be  mistaken  for  cancer.  There  are 
two  forms  of  tertiary  disease,  sclerosis  and  gumma  of  the  tongue. 
Both  occur  in  inherited  as  well  as  acquired  disease. 

Sclerosis  of  the  Tongue. — This  affection  has  been  well  described  by 
Fournier.*  There  are  two  forms,  one  superficial,  in  which  the  mu- 
cous and  submucous  tissues  thicken  up  into  hard,  rounded  patches  on 
the  front  and  middle  portions  of  the  dorsum  of  the  tongue,  several 
being  prc.'^ent  at  the  same  time,  the  hardening  and  thickening  being 
palpable,  tlie  color  of  the  patches  dark,  their  surface  smooth  and 
shining  on  account  of  epithelial  thickening.  The  whole  dorsum  of 
the  tongue  may  be  involved  and  look  like  scar-tissue,  perhaps  seamed 
by  ulcerated  fissures,  and  with  ragged  ulcers  on  the  sides  of  the  tongue. 
This  form  is  only  an  exaggeration  of  the  scaly  patch  already  described. 
The  deeper  form  of  sclerosis,  which  is  generally  also  attended  by  the 
superficial  form,  may  result  in  a  local  or  general  tliickening  of  the 
tongue  yielding  a  lobulated  condition  of  the  dorsum,  tlic  lobules  being 
separated  by  fissures,  of  which  the  central  fissure  is  the  most  pro- 
nounced. The  tongue  is  felt  to  be  hardened  as  well  as  thickened, 
the  surface  is  mottled,  red,  jiale,  and  dirty-white,  according  to  the 
thickness  of  the  epithelial  covering.  It  is  generally  smooth.  Four- 
nier has  described  one  case  of  great  hypertrophy  of  the  tongue  due  to 
this  malady.  Partial  atrophy  may  finally  result,  owing  to  ultimate 
atrophy  of  the  newly-formed  tissue. 

Gumma  of  the  Tongue,  generally  a  very  late  symptom  (although 
Mauriac  has  reported  a  case  in  the  seventh  month),  may  attack  any 
part  of  the  tongue.  The  superficial  ones  in  the  mucous  membrane 
are  small  and  develop  as  complications  of  the  sclerotic  patches.  The 
deep  gumma  commences  as  a  small,  hard,  painless  swelling  beneath 
the  mucous  membrane  or  in  the  thickness  of  the  tongue.  Lagneau  f 
liad  given  an  excellent  description  of  these  tumors.  These  grow  slowly 
to  the  size  of  a  pea  or  nut,  the  mucous  membrane  over  them  being  at 
first  perfectly  healthy.  Then  the  tumor  softens  centrally,  the  mem- 
brane over  it  becomes  violet-colored,  finally  ulcerates,  letting  out  the 
gummy  matter,  if  it  has  become  sufficiently  softened  and  degenerated, 
or  exposing  it  to  view  as  a  yellow,  false-membranous-looking  mass, 
firmly  adherent  and  gradually  deliquescing  and  sloughing  away.  These 
ulcers  are  indurated  at  their  base  and  sides,  sometimes  sprinkled 
with  gangrenous  points.     They  bleed  easily.    The  surrounding  tissues 

*  "  Des  Glossites  lertiaires,"  Paris,  1811. 
f  "Archives  de  Med.,"  I,  1,  1860,  p.  211 


SYPHILIS  OF  THE  TONGUE.  f555 

tire  reddened,  thickened,  codematous.  The  ulcer  may  take  the  shape 
of  a  deep,  ragged,  oval  fissure  into  the  side  of  the  tongue  or  across  its 
dorsum.  The  edges  are  raised  and  hard,  but  not  tuberculated.  Por- 
tions of  the  edges  are  often  undermined.  These  ulcers  have  a  very 
slowly  progressive,  destructive  action,  but  even  without  treatment  they 
are  often  self-limiting,  and,  after  more  or  less  destruction  of  lingual 
tissue,  the  borders  sometimes  flatten  down,  soften,  granulations  spring 
up  and  cicatrization  ensues,  perhaps  at  the  expense  of  considerable 
deformity  of  the  organ  from  loss  of  tissue.  Eelapse  is  possible  in  an 
old  scar  left  behind  by  a  gumma. 

The  beginning  of  this  affection  often  passes  unnoticed.  It  may  be 
impossible  to  distinguish  the  tumors  except  by  pressing  the  tongue  be- 
tween the  thumb  and  finger,  when  one  or  more  hard,, interstitial  lumps 
are  felt.  During  ulceration  the  saliva  collects  abundantly  and  dribbles 
away  over  the  lower  lip,  the  mouth  being  kept  ajar  for  fear  of  press- 
ing on  the  tongue.  These  symptoms  continue  more  or  less  marked 
according  to  the  extent  of  the  ulcers.  There  may  or  may  not  be 
syphilitic  cachexia,  with  gummy  tumor  of  the  tongue. 

Diagiiosis. — These  ulcers  of  the  tongue  are  very  apt  to  be  mistaken 
for  cancer.  They  usually  do  not  return  after  extirpation,  and  may 
get  well  during  a  sojourn  at  this  or  that  sjDring,  or  while  the  jDatient 
is  consuming  this  or  that  nostrum,  and  thus  become  evidences  of  the 
cure  of  cancer.  In  five  clinical  points,  however,  gummy  ulcerations 
differ  from  cancer  of  the  tongue  : 

1.  They  commence  as  submucous  lumps,  not  as  superficial  warty 
growths. 

2.  The  edges  of  the  syphilitic  ulcer  are  not  tuberculated. 

3.  The  submaxillary  glands  are  involved  late  in  cancerous  ulcer, 
but  not  at  all  with  the  syphilitic. 

4.  In  the  syphilitic  ulcer  of  some  duration  it  is  customary  to  find 
certain  points  cicatrized  ;  not  so  in  cancerous  disease. 

5.  Cancerous  disease  is  somewhat  painful  from  the  first,  and  espe- 
cially so  after  ulceration,  the  pain  radiating  toward  the  ear  (Fournier). 
The  distress  on  using  the  tongue  is  greater,  the  sloughy  condition  of 
the  base  likely  to  be  worse.  With  gumma  there  is  no  pain  until  the 
lump  softens  and  ulcerates,  and  sometimes  then  not  as  much  as  one 
would  expect  to  find. 

Zeissl  has  pointed  out  that  sometimes  in  epithelial  cancer  of  the 
tongue  pressure  will  squeeze  out  little  plugs  of  sebaceous  matter,  not 
so  in  the  case  of  ulcerated  gumma.  Hutchinson  has  drawn  attention 
to  the  possible  development  of  epithelial  cancer  upon  a  chronic  con- 
dition of  syphilitic  disease  of  the  tongue.  In  such  case,  diagnosis 
might  be  difficult. 

With  tubercular  ulcer  of  the  tongue,  a  rare  disease,  diagnosis  must 
be  made  mainly  by  attention  to  the  history  of  the  case,  an  examina- 


656  VISCERAL  SYPHILIS. 

tion  for  the  bacillus  of  tubercle,  and  especially  by  the  commencement 
of  the  ulcer,  which  in  the  case  of  tubercle  always  starts  superticially 
without  antecedent  thickening.  Eicord,  Portal,  Tr^lat,  Fer6ol,  Good- 
lee,  and  others  have  called  attention  to  tubercular  disease  of  the 
tongue  and  noted  its  special  features.  The  tubercular  ulcer  of  the 
tongue  is  very  iincommon.  I  have  seen  it  once  on  the  inside  of  the 
check,  once  on  the  gum,  but  never  upon  the  tongue.  It  is  likely  to 
coincide  with  tubercular  disease  elsewhere. 

Treatment  of  gummy  tumors  of  the  tongue  is  usually  rapidly  effect- 
ive if  undertaken  before  they  have  ulcerated.  After  the  ulcerations 
have  become  chronic  they  are  very  slow  in  yielding,  but  persevering 
effort  will  master  them  unless  the  patient  be  irremediably  depressed  by 
cachexia,  and  can  uut  digest  the  iodides. 

Syphilis  of  the  (Esophagus. — Syphilitic  ulceration  occasionally 
attacks  the  oesophagus,  either  by  extension  from  the  pharynx  or  as  a 
local  gummy  deposit.  West*  first  called  attention  to  these  lesions. 
Virchow  has  found  cicatrices  and  stricture  of  the  oesophagus  in  autop- 
sies of  syphilitic  jjatients.  Maury, f  of  Philadelphia,  details  a  case 
uj)on  which  he  was  forced  to  the  performance  of  gastrotomy. 

Symptoms  of  stricture  with  difficult  deglutition  usually  first  call 
attention  to  the  affection  under  consideration.  The  stricture  is  the 
result  of  cicatrization  of  previous  ulceration,  and  is  therefore  but  little 
benefited  by  treatment.  Some  relief  has,  however,  been  noticed  in 
cases  which  have  been  diagnosticated.  A  cure  is  reported  in  one  case 
by  Follin,J  but  the  treatment  is  mainly  that  of  stricture  of  the  oesoph- 
agus by  dilatation,  etc. 

Syphilis  of  the  Stomach  and  lNTESTi]<rE. — Functional  derange- 
ments of  the  stomach  and  intestines  are  common  early  in  secondary 
syphilis  and  in  the  cachectic  stage.  Loss  of  appetite  is  common,  early 
and  late  in  the  disease.  Excess  of  appetite,  bulimia,  is  more  rare. 
Fournier  describes  it  fully,  and  found  it  often  combined  with  head- 
ache, nausea,  pain,  high  temperature,  great  thirst,  polydipsia.  Some- 
times the  extra  amount  of  food  is  kindly  digested,  at  others  it  causes 
in  its  turn  the  customary  stomach  derangements.  Chronic  vomiting  is 
another  of  the  functional  disorders  which  has  been  noted.  All  these 
derangements  occur  in  the  first  half-year  after  chancre,  and  get  well 
spontaneously  in  a  time  varying  from  a  few  days  to  several  months. 
Antisyphilitic  treatment  does  not  appear  to  benefit  them.  I  have 
seen  one  case  of  well-marked  bulimia  and  one  of  pronounced  polydip- 
sia in  the  tertiary  stage.  Both  got  well  after  some  weeks  during 
treatment,  but,  whether  because  of  treatment  or  independently  of  it, 
I  can  not  say. 

*  "Dublin  Quarterly,"  February,  1860. 

t  "American  Journal  of  Medical  Sciences,"  April,  1870. 

X  "  Traite  61em.  de  Path,  cxt.,"  tome  i,  p.  696,  1861. 


SYPHILIS  OF  THE  STOMACH   AND   INTESTINE.  057 

Tertiary  ulcers  have  also  been  occasionally  found  in  the  stomach 
and  intestines,  and  local  brawny  thickenings  (Wagner,*  Lancereaux,t 
Cornil,J  Engel,  and  others),  without  ulceration.  Tliere  are  no  means 
of  diagnosticating  these  lesions,  except  continuous  diarrhoea  with  oc- 
casional bloody  stool  and  colicky  pains,  or  eructations  and  vomiting, 
together  with  the  coexistence  of  a  syphilitic  history,  visible  lesions 
elsewhere,  and  more  or  less  cachexia.  Both  the  large  and  small  intes- 
tines suffer,  and  Peyer's  patches  seem  to  have  been  particularly  elected 
by  the  disease  as  the  seat  of  ulceration  in  some  cases  (Oser,  Meschede). 
Klebs  *  quotes  a  case  from  Virchow,  a  syphilitic  man  of  thirty-six, 
who  had  fifty-four  ulcers  in  the  small  intestine  from  two  lines  to  two 
inches  long,  and  some  circular  stellate  fibrous  cicatrices  on  pigmented 
bases.  There  were  small,  tough  fibrous  nodules  on  the  corresponding 
serous  surfaces.  I  have  seen  an  almost  precisely  similar  case — a  man 
of  about  thirty-five,  with  a  syphilitic  history  and  a  very  well  marked 
ano-rectal  syphiloma,  who  died  in  cachexia  after  repeated  intestinal 
haemorrhages.  His  small  and  large  intestines  were  the  seat  of  numer- 
ous oval  and  circular  ulcers  and  cicatrices  with  pigmented  borders, 
with  thickening  of  the  peritonaeum  under  some  of  the  ulcers,  and  scars 
and  some  points  of  adhesion.  The  ano-rectal  syphiloma  had  nearly 
healed  under  treatment,  when  the  haemorrhage  carried  off  the  patient. 
Klebs  has  also  a  personal  case  of  numerous  ulcerations  in  the  intestines 
of  a  man  dying  with  acute  manifestations  of  syphilis.  A  case  of  nu- 
merous ulcers  and  nodules  in  the  upper  half  of  the  caecum  in  a  pros- 
titute of  twenty-five,  who  died  in  the  third  year  of  syphilis,  having 
active  lesions  at  the  time,  is  reported  by  Blackmore.  I 

'The  anus  and  rectum  have  been  most  especially  studied  and  most 
carefully  described  by  Fournier.^^  There  may  be  ulcers  uj)on  the  mu- 
cous membrane  of  the  rectum,  behaving  like  syphilitic  ulcers  else- 
where. They  are  usually  the  result  of  the  extension  upward  of  syphi- 
litic ulcers  at  the  anus.  Localized  gummata  of  the  rectum  and  its 
neighborhood  have  been  noted  (Zeissl).  The  ano-rectal  syphiloma  of 
Fournier  is  a  hyperplastic  infiltration  into  the  submucous,  subcutane- 
ous, and  muscular  tissues  of  the  rectum  and  anus.  This  eventuates 
in  ulceration  of  the  rectum  about  the  anus,  and  within  the  gut,  and 
leads  to  a  deepening  of  the  radiate  furrows  about  the  anus  and  to  su- 
perficial fistulffi.  Finally,  this  affection  goes  on  to  form  stricture  of 
the  rectum.  AUingham  ^  describes  a  syphilitic  stricture  of  the  rec- 
tum, which  he  states  that  he  cured  by  internal  treatment.     Trelat  % 

*  "  ArcMv  der  Heilkunde,"  1863.  f  Oj).  cif.,  p.  248. 
t  "  Le90us  sur  la  Syphilis,"  1879,  p.  406. 

*  "  Hdbch.  d.  path.  Anat.,"  2te  Lief.,  p.  261. 
II  Blackmore,  "Lancet,"  Oct.  3,  1885,  p.  615. 
■^  "Syphil&me  ano-rectal,"  Paris,  18*75,  p.  73. 
^  "Dis  of  Rectum,"  London,  1871,  p.  187. 

^  "Prog.  Med.,"  June,  1878,  p.  473. 
42 


658  VISCERAL   SYPHILIS. 

believes  firmly  in  syphilitic  stricture  of  the  rectum,  and  the  efficacy  of 
treatment,  lie  thinks  the  multiple  dry  tistula;  from  below  the  point 
of  stricture  are  pathognomonic,  and  thinks  the  stricture  proper  is  due 
to  interstitial  absorption  of  hyperplastic  exudation  and  not  to  cicatri- 
zation of  ulceration. 

Syphilis  of  the  Paxcreas. — Lancereaux  has  found  the  pancreas 
indurated  in  syphilitic  autopsies,  and  gummy  tumors  of  the  same  or- 
gan have  been  observed.  No  special  symptoms  mark  the  allection 
during  life. 

Syphilis  of  the  Spleex. — Syphilis  may  occasion  a  partial  or 
general  splenitis,  gummy  tumor  of  the  organ,  or,  according  to  Lance- 
reaux, an  hypertrophy  l\v  augmentation  of  the  cellular  contents  or 
pulp.  Weil*  lias  called  attention  to  a  congestive  enlargement  of  the 
spleen,  which  he  states  comes  on  in  the  secondary  period  and  disap- 
pears under  treatment.  Barlow  f  refers  to  Gee's  report  to  the  Eoyal 
Medical  and  Chirurgical  Society  in  1867,  to  the  effect  that  the  spleen 
may  be  felt  during  life  in  fifty  per  cent  of  cases  of  inherited  disease, 
in  corroboration  of  it,  and  states  his  belief  that  the  change  is  not 
gummatous  or  amyloid,  but  hard  hypertrophy,  and  that  it  may  dis- 
appear entirely  under  treatment.  Werner  J  states  that  7 '5  percent 
of  syphilitic  patients  have  enlargement  of  the  spleen,  which  may  be 
detected  in  from  eight  to  twelve  weeks  after  infection.  It  continues 
from  four  to  eight  weeks,  and  is  favorably  influenced  by  a  mercurial 
course.  Undoubtedly  in  inherited  disease  the  changes  in  the  spleen  of 
an  organic  sort  are  most  often  observed.  Great  thickening  of  the  cap- 
sule of  the  spleen  up  to  one  inch  has  been  observed  by  Buzzard.  ** 
Bloch,||  from  records  of  post-mortems  in  the  City  Ilosjiital  at  Copen- 
hagen, for  the  past  five  years,  decides  that  there  is  syphilitic  hyper- 
plasia of  the  spleen  in  SG^V  per  cent  in  children  with  inherited  dis- 
ease. In  the  adult  witli  acquired  disease  he  rates  it  even  higher, 
61-j^  per  cent. 

In  splenitis  the  portions  affected  become  hardened,  dry,  dark-col- 
ored, so  dark  as  to  be  sometimes  mistaken  for  hfemorrhagic  foci  (Vir- 
chow),  and  difficult  to  distinguish  from  inflammatory  engorgements. 
As  the  newly-formed  connective  tissue  contracts,  the  affected  portion 
grows  harder  and  paler,  and  its  site  is  marked  by  a  dejiression  of  cica- 
tricial character.  A  certain  amount  of  perisplenitis  may  also  occur, 
occasioning  adhesions  between  the  sjileen  and  neighboring  tissues  and 
organs. 

Gummy  tumors  of  the  spleen  resemble  the  same  productions  in 

*  "Dcutsch  Archiv  f.  klin.  Med  ,"  May  15,  ISV^ 

f  "Trans.  Lond.  Path.  Soc,"  xxviii,  p.  353. 

t  "Deutsch.  Archiv  f.  klin.  Med.,"  1876,  p.  459. 

»  "Lancet,"  Feb.  10,  1877,  p.  197. 

j  " Posp.-Tidende,"  ix,  2  and  3,  1882,  and  "Med.  News,"  July  8,  1882,  p.  37. 


SYPHILIS   OF   THE    LIVER.  059 

other  organs.  They  occur  as  one  or  more  rounded  nodosities,  of  dirty 
yellowish-white  color  on  section,  more  often  superficial  than  deeply 
seated.     They  are  of  rare  occurrence. 

In  inherited  disease  the  spleen  is  often  firmer  and  larger  than  usual ; 
rarely  the  scat  of  circumscribed  or  diffused  gummy  infiltration.  Lesions 
of  the  spleen  rarely,  if  ever,  occur,  except  coincidently  with  other  vis- 
ceral changes. 

In  syphilitic  cachexia  amyloid  changes  are  found  in  the  spleen  as 
in  other  organs. 

Syphilis  of  the  Liver. — No  viscus  is  more  subject  to  alteration 
from  syphilis  than  the  liver.  This  is  especially  true  in  cases  of  inher- 
ited disease.  Gubler,*  Dittrich,f  Virchow,J  Wilks,*  Lancereaux,|| 
Diday,^Frerichs,^  and  others  have  done  much  toward  elucidating  the 
changes  wrought  by  syphilis  in  the  liver.  There  are  in  this  organ  two 
distinct  forms  of  syphilitic  disease  besides  the  simple  catarrh  of  the 
ducts,  causing  jaundice  with  secondary  syphilis,  never  lasting  more 
than  a  month,  and  always  terminating  in  recovery  (Lancereaux)  and. 
the  amyloid  degeneration  so  common  in  the  late  stages  of  the  disease. 
Goodhart  |  puts  the  percentage  of  amyloid  disease  in  some  organ  in 
the  body  upon  the  post-mortem  of  syphilitic  subjects  in  Guy's  Hospi- 
tal as  high  as  43^. 

Frerichs,  Virchow,  and  others  lean  somewhat  to  a  belief  that  local 
violence,  contusions,  etc.,  have  something  to  do  with  bringing  out  a 
local  expression  of  syphilis  in  the  liver. 

The  two  common  methods  of  manifestation  are — 

1.  Interstitial  syphilitic  hepatitis. 

2.  Gummy  tumor. 

In  inherited  disease  both  forms  are  also  found,  but  the  first  is  very 
much  more  common  than  the  second. 

1.  Interstitial  Syphilitic  Hepatitis. — This  is  a  chronic  cell-hyper- 
plasia,  occurring  either  in  patches  in  the  capsule  of  the  gland  (peri- 
hepatitis) or  in  the  parenchyma,  diffused,  or  generally  in  patches. 
The  generalized  form  occurs  only  in  inherited  disease.  There  is  first 
hypergemia,  then  new  formation  of  cells  along  the  course  of  the  vessels, 
with  local  or  general  increase  in  the  size  of  the  organ  ;  finally,  shrink- 
age of  the  newly-formed  tissue,  and  consequent  compression  of  the 
glandular  elements,  ducts,  and  vessels  of  the  organ.  On  the  surface 
these  patches  implicate  the  peritoneum,  and  adhesions  take  place  with 
the  neighboring  structures.  The  irregular  contractions  pucker  in  and 
depress  the  liver-surface  unevenly,  leaving  it  seamed,  fissured,  and  dis- 

*  "  Mem.  de  la  Soc.  de  Biol.,"  t.  iv. 

f  "Prager  Vierteljahrschrift,"  1849-50.  %  Op.  cit. 

*  "Guy's  Hospital  Report,"  1863.  |  Op.  cit. 
^  "  Syphilis  in  New-born  Children,"  "  Sydenham  Soc.  Trans." 

0  "Diseases  of  the  Liver."  ;J;  "Trans.  Path.  Soc,"  1879,  p.  533. 


660  VISCERAL   SYPHILIS. 

tortod.  The  whole  orfran,  or  part  of  it,  finally  becomes  contracted,  cir- 
rhosed,  hardened,  intersected  by  seams  and  lines  of  contracted  fibrous 
tissue  more  or  less  thick.  The  color  of  a  section  is  yellowish,  some- 
times darkened,  the  glandular  elements  are  withered,  fatty,  or  com- 
pletely atrophied,  sometimes  enlarged,  amyloid  :  a  darkened  spot  may 
mark  the  position  of  an  occluded  bile-duct.  The  walls  of  the  capil- 
laries may  undergo  amyloid  degeneration  (Lancereaux).*  Gummy  tu- 
mor not  uncommonly  coexists  with  this  form  of  disease. 

The  liver,  in  cases  of  death  from  inherited  syphilis,  has  rarely  had 
time  to  contract.  It  is  found  enlarged,  globular,  hard,  elastic,  so  that, 
when  a  portion  is  pinched  between  the  fingers,  it  slips  away  like  a  piece 
of  cartilage,  and  does  not  receive  the  impression  of  the  fingers.  The 
proliferation  of  connective  tissue  seems  often  to  go  on  to  the  extent  of 
separating  the  liver-cells  themselves  from  each  other.  It  may  creak 
under  the  scalpel  like  fibrous  tissue.  The  color  is  of  a  yellowish-pink 
on  section,  shaded  with  brown.  Small  white  spots  appear  on  the  sur- 
face of  a  section,  with  delicate  white  streaks  radiating  from  them 
formed  of  collapsed  thickened  blood-vessels.  The  vessels  are  mostly 
empty,  so  that  not  much  blood  can  be  squeezed  from  a  section.  The 
bile  in  the  gall-bladder  is  of  jiale  color  and  sticky  consistence,  showing 
deficiency  in  coloring  matter  and  excess  of  mucus  (Gubler).  Extrava- 
sations of  blood  into  the  liver  substance  may  have  occurred.  The  solid 
portions  of  blood  resemble  soft  currant-Jelly.  The  changes  above  de- 
tailed may  occupy  the  whole  or  only  a  portion  of  the  liver,  or  of  one  of 
its  lobes.  Amyloid  degeneration  of  the  caj^illaries  and  liver-cells  is 
not  uncommon.  Distinct  gummy  tumors  have  also  been  found  in  the 
liver  in  inherited  syphilis,  in  connection  with  the  above  changes. 

2.  Gummy  Tumor  of  the  Liver. — These  tumors  occur  in  the  liver 
as  hard,  irregularly  rounded,  yellowish-white  masses  of  difi'crent  sizes. 
They  occur  in  the  midst  of  portions  of  liver  affected  by  interstitial 
hepatitis,  often  just  under  the  capsule.  The  newly-formed  connect- 
ive tissue  is  continuous  into  them,  its  meshes  widening  to  receive  the 
numerous  small  nucleated  cells  constituting  gummy  deposit.  These 
masses  are  yellowish,  hard,  dry,  and  can  often  be  easily  separated  from 
the  surrounding  tissues.  A  thick,  retractile  zone  of  fibrous  tissue  sur- 
rounds each  gummy  tumor,  or  group  of  them,  so  that,  when  cut 
through  on  section  of  the  liver,  the  tumor  stands  out  prominently 
above  the  cut  surface  (Lancereaux).  Peripherally  the  tumors  consist 
of  fibers  and  cells,  centrally  of  cells  more  or  less  shrunken,  granular, 
undergoing  fatty  metamorphosis  preparatory  to  absorption.  Centrally 
free  oil-globules  and  granular  detritus  also  abound,  with  sometimes 
cholesterin  (Lancereaux  f).  Occasionally  the  whole  gumma  is  soft 
enough  to  suggest  abscess  (AYilkes,!  Moxon).*     These  tumors  are  capa- 

*  "  Gaz.  mdd.  de  Paris,"  18Y3,  Nos.  27  and  29.  t  Hid. 

X  "Lancet,"  December  8,  IST?,  p.  845.         *  "Path.  Trans.,"  vol.  xxiii,  1SY2,  p.  153. 


SYPHILIS   OF  THE   LIVER.  f;(31 

ble  of  absorption,  leaving  depressed  hard  cicatrices,  fibrous  in  char- 
acter, often  stellate  in  appearance,  and,  if  on  the  surface  of  the  organ, 
attached  by  strong  peritoneal  adhesions  to  the  diaphragm  or  other 
adjacent  structure.     They  rarely  calcify,  but  do  so  occasionally. 

Fatty  and  amyloid  degeneration  of  the  liver,  often  found  in  syphi- 
litic subjects,  is  not  essentially  due  to  syphilis  as  a  cause,  yet  the  coin- 
cidence of  amyloid  degeneration  of  the  spleen,  liver,  and  kidneys  with 
the  visceral  lesions  of  syphilis  is  noteworthy.  Amyloid  degeneration 
of  the  liver  is  very  common  in  inherited  syphilis,  and  in  the  adult 
Frerichs  *  thinks  that  syphilis  is  one  of  its  most  common  predisposing 
causes. 

Acute  yellow  atrophy  of  the  liver,  accompanied  by  Jaundice,  fever, 
local  tenderness,  and  death,  is  mentioned  by  several  writers  as  occa- 
sionally occurring  during  syphilis,  and  as  possibly  due  to  it. 

Symptoms  of  SypMUtic  Hepatitis. — Early  in  the  disease  the  liver 
becomes  enlarged,  later  contracted,  and  both  of  these  changes  are 
appreciable  by  palpation  and  percussion.  If  amyloid  degeneration  be 
marked,  the  liver  may  be  enlarged  to  the  end,  sometimes  very  con- 
siderably. The  inequalities  and  fissures  of  the  surface  can  occasionally 
be  felt  during  life.  Sometimes  there  is  a  little  local  pain  or  uneasi- 
ness, especially  on  pressure.  The  gland  is  apt  to  be  unevenly  enlai"ged, 
one  lobe  disproportionately  larger  than  the  other.  Adhesions  may  be 
sometimes  made  out.  Jaundice  is  exceptional,  and,  when  it  occurs, 
may  be  transitory,  or  progressive  and  of  long  duration.  It  is  due 
sometimes  to  pressure  upon  the  excretory  duct  of  the  liver  by  enlarged 
abdominal  lymphatic  glands,  or  by  the  contractions  of  a  cicatrix  (Fre- 
richs), sometimes  to  catarrh  of  the  bile-ducts.  Jaundice  sometimes 
comes  on  several  years  before  any  appreciable  signs  of  textural  trouble 
have  been  furnished  by  the  liver.  Ascites  is  liable  to  appear  after  the 
liver  has  become  contracted.  Epistaxis,  hsemorrhoidal,  bleeding,  di- 
gestive troubles,  anasarca,  discolored  or  brownish  bloody  stools,  dense, 
high-colored,  scanty,  perhaps  albuminous  urine,  etc. — accompaniments 
of  cirrhosis — may  be  also  found  with  the  contracted  syphilitic  liver. 
Tendency  to  cachexia  is  more  or  less  marked.  No  instance  has  been 
recorded  of  a  gummy  tumor  of  the  liver  softening  and  discharging 
into  the  peritonseum.  Absorption  is  the  rule  for  all  such  deposits 
here.  Lancereaux  gives  three  symptoms  which,  when  coinciding 
with  a  syphilitic  history,  are  sufficient  to  make  a  diagnosis  of  syphi- 
litic hepatitis.  They  are — irregularity  in  the  form  of  the  liver,  espe- 
cially if  rounded  ;  indurated  lumps  which  can  be  felt  on  the  surface  or 
fissures  of  the  edge  ;  albuminuria  and  cachexia.  In  the  infant,  the 
symptoms  of  hepatitis  are  restlessness,  rise  of  pulse  and  temperatui-e, 
perceptible  increase  in  size  of  the  organ,  local  tenderness,  vomiting, 
diarrhoea  or  constipation  ;  very  rarely,  if  ever,  jaundice. 

*  "Wiener  med.  Wochenschrift,"  1860,  p.  113. 


QQ2  VISCERAL   SYPHILIS. 

Treatmcjif  i?  tluit  of  late  syphilis,  or  by  innnction  in  the  infant. 
The  gumma  yields  more  promjitly  to  the  iodides  than  the  dilluse  form, 
which  requires  mixed  treatment. 


SYPHILIS    OP    OTHER    INTERNAIi    ORGANS    AND    TISSUES. 

The  jJeritoncrion  may  become  thickened  in  connection  with  syphi- 
litic changes  near  the  surface  of  the  liver  or  spleen,  both  in  children 
and  adults — and  over  patches  of  diseased  tissue. 

Changes  due  to  parenchymatous  inflammation  or  occasional  gummy 
deposit  have  (very  rarely)  been  noted  in  the  thyroid  and  salivary  glands. 
The  thymus  in  inherited  disease  has  attracted  attention  since  the  in- 
vestigations of  Dubois,  first  published  in  1850.*  This  organ,  usually 
found  healthy,  may  be  the  seat  of  ditTused  ijuriform  infiltration,  or  a 
material  resembling  pus  may  be  found  collected  in  one  or  several  cavi- 
ties. Ilypertrophicd  portions  of  connective  tissue,  in  a  state  of  fatty 
degeneration,  have  been  encountered  in  the  thymus  by  Lehmann.f 

Thus  it  would  seem  that  the  thymus,  like  most  other  internal 
organs,  is  subject  to  two  forms  of  syphilitic  attack  :  a  diffuse  paren- 
chymatous inflammation  with  connective-tissue  hyperplasia,  going  on, 
it  would  seem,  to  softening,  and  gummy  tumor,  also  softening  and 
forming  a  cavity  full  of  puriform  fluid,  but  not  true  pus. 

Other  observers  (Depaul,  Weld)  have  studied  these  changes. 
Parrot  J  believes  that  the  trouble  is  not  syphilitic,  but  due  to  malnu- 
trition. In  a  majority  of  the  cases  of  inherited  syphilis  the  thymus  is 
unaltered. 

SYPHILIS    OF    THE    GENITO-TJEINARY    SYSTEM. 

The  urethra  in  the  male  it  is  alleged  sometimes  discharges  slightly 
during  secondary  syphilis.  H.  Lee  thinks  there  are  two  varieties, 
one  occurring  with  chancre,  the  other  later.  Various  observers  have 
noted  ulcerations  of  the  urethra  and  bladder  in  both  sexes  in  syphi- 
litic patients.  Proksch  *  collected  six  cases  :  one  Morgagni,  two 
Ricord,  one  Virchow,  one  Vidal  de  Cassis,  one  Tarnowsky.  The  cer- 
tainty that  these  ulcers  were  syphilitic  is  not,  however,  assured.  Oed- 
mansson  |1  has  raised  the  doubt  by  his  six  cases.  Yet  Tarnowsky's 
case  seems  to  cover  the  ground.  A  boy  of  four,  with  syphilis  acquired 
from  his  nurse,  covered  with  eruptions  and  mucous  patches,  showed 
on  autopsy  the  mucous  membranes  of  the  bladder  and  urethra  sprinkled 
with  superficial  ulcers.     The  liver  and  one  lung  were  syphilitic.     Tu- 

*  "Gaz.  m6d.  de  Paris,"  1850  and  ISTA. 

f  "  Wurzburgcr  mcd.  Wochenschrift,"  vol.  iv,  18G3,  p.  7. 
X  "Proj;rt'S  med.,"  1818,  p.  655. 

*  "  Yrtljahresschrift.  f.  Derm.  u.  Syph.,"  1879,  vol.  iv,  555. 
I  Cited  in  "Gaz.  hebd.,"  IS/?,  December  Vth,  p.  782. 


SYnilLIS   OF   THE   GENITO-URINARY   SYSTEM.  G03 

bercular  sypliilidc  of  the  urethra  and  gumma  have  been  observed. 
The  syphilitic  alTcctions  of  the  cord,  epididymis,  and  testicle  are  con- 
sidered when  treating  the  diseases  of  these  parts  in  the  first  section  of 
this  treatise.  The  vulva,  vagina,  and  uterine  cervix  are  liable  to 
show  many  of  the  primary,  secondary,  and  tertiary  lesions.  Men- 
strual disturbances  may  be  produced  by  the  disease,  and  leucorrhoea, 
even  without  ulcerative  lesion,  is  alleged  by  some  authors  to  be  capa- 
ble of  conveying  the  disease  by  contagion.  The  ovaries,  the  uterus, 
the  tubes,  the  placenta,  are  all  subject  to  syphilitic  changes,  more 
especially  the  placenta,  which  may  be  affected  in  its  maternal  part,  its 
fetal  part,  and  in  the  vessels  of  the  cord.  The  changes  are  a  harden- 
ing of  and  thickening  of  the  parts  from  interstitial  hyperplastic 
change,  fatty  and  calcific  deposits,  cheesy  points,  and  positive  gum- 
matous nodules.  The  vessels  of  the  cord  suffer  as  in  syphilitic  arteri- 
tis. The  ureters  and  pelves  of  the  kidneys  have  not  yet  sent  in  their 
contribution  to  syphilitic  pathology,  but  doubtless  they  will  one  day 
do  so. 

The  hidneys  are  more  often  affected  by  syphilis  than  other  parts  of 
the  urinary  tract.  The  albuminuria  attending  treatment  has  been 
already  alluded  to,  and  the  syphilitic  considered  along  with  the  other 
diseases  of  the  kidney  in  the  first  part  of  this  treatise.  The  supra- 
renal capsules  have  been  found  enlarged  in  syphilitic  patients,  infil- 
trated, hard,  sprinkled  with  miliary  granules,  and  in  a  state  of  fatty 
degeneration.  I  do  not  know  that  positive,  well-defined  gumma  has 
been  observed. 


CHAPTEE  XII. 

SYPHILIS   OF  TEE  NERVOUS  SYSTEM. 

The  Lesions  :  Symptoms,  Prognosis,  Treatment.— General  Characteristics  of  Nervous  Symptoms  in 
all  Cases.— Syphilis  of  the  Brain.— Syphilis  of  the  Cord.— Syphilis  of  Special  jSTerves. 

That  syphilis  may  produce  textural  changes  in  the  nervous  cen- 
ters is  now  universally  admitted.  Numerous  and  exhaustive  essays 
and  monographs  have  been  written  on  the  subject,  and  mucli  is  yet  to 
be  learned.  Space  allows  only  an  outline  of  the  subject  to  be  given 
here. 

The  literature  of  the  subject  has  become  very  extensive.  The 
French,  from  the  year  1853  (Yvaren)  onward,  have  been  the  largest 
contributors  to  our  know^ledge  on  this  subject,  until  Virchow  asserted 
the  claims  of  Germany,  and  lleubner,  in  his  masterly  treatise  on  syphilis 
of  the  cerebral  arteries,  opened  an  entirely  new  field  for  investigation 
into  which  modern  workers  have  gladly  followed  him.     The  English 


664  SYPHILIS   OF   THE   NERVOUS   SYSTEM. 

veiT  early  (Biuld,  in  1842  ;  Readc,  of  Dublin,  in  1852)  raised  the  ques- 
tion of  syphilitic  brain-disease.  Of  late  years  England  has  done  much 
excellent  work  in  this  direction.  In  18T0  I  published  in  the  "  New 
York  3Iedical  Journal "  an  analysis  of  thirty-foiir  cases  derived  from 
the  records  of  Dr.  Van  Buren  and  myself.  Fifty  new  personal  cases 
furnished  the  material  from  -which  the  deductions  of  the  first  edition 
of  this  treatise  were  largely  drawn.  Later  experience  since  that  date 
has  given  me  the  impression  that  a  considerable  proportion  of  all 
chronic  cerebral  disease.,  as  customarily  encountered  in  routine  prac- 
tice, has  syphilis  for  its  underlying  cause.  This  statement  is  too  gen- 
eral to  be  ap]ilied  justly  to  individual  cases,  yet  it  is  a  matter  to  be 
borne  in  mind.  The  nervous  diseases  occur  as  a  rule  so  late  after 
infection  that  the  patient  is  often  ignorant  of  the  association,  and 
motives  of  delicacy  restrain  him  from  furnishing  his  physician  WMtli 
necessary  evidence  in  most  instances  unless  he  is  urged  thereto  w'ith 
considerable  force. 

Syphilitic  disease  of  the  nervous  system  occurs  in  inherited  and  in 
acquired  disease  through  the  instrumentality  of  four  causes  : 

1.  Lesions  of  the  bony  envelopes. 

2.  Lesions  of  the  enveloping  membranes. 

3.  Lesions  of  the  substance  of  the  brain  and  cord. 

4.  Lesions  of  the  cerebral  arteries. 

1.  Lesions  of  the  Bony  Envelopes. — The  bones  of  the  cranium 
are  particularly  liable  to  disease  in  bad  cases  of  tertiary  syphilis,  in  the 
shape  of  dry  caries,  nodes,  necrosis,  etc.  If  these  lesions  affect  only 
the  outer  table  and  the  diploe,  the  functions  of  the  brain  are  not  dis- 
turbed ;  but,  if  the  inner  table  be  involved,  as  it  not  infrequently  is, 
an  internal  node — by  pressure — or  a  gummy  deposit,  or  caries,  involv- 
ing the  dura  mater  in  disease,  is  fully  competent  to  occasion  paralysis, 
convulsions,  and  disturbances  of  function  of  the  most  varied  charac- 
ter. The  same  remarks  hold  true  of  the  bony  envelo^ie  of  the  spinal 
cord,  though  here  bone-lesions  are  far  less  common  than  in  the  skull. 
Again,  periosteal  thickenings  or  disease  of  bone  about  the  narrow 
canals  through  which  nerves  emerge  are  accompanied  by  loss  of  func- 
tion of  the  nerve,  as  facial  paralysis  from  pressure  of  the  seventh  nerve, 
neuralgia  in  any  of  the  branches  of  the  fifth  pair. 

2.  Lesions  of  the  Membkanes  of  the  Beain  and  Cord. — These 
are  of  two  kinds  (both  far  more  common  for  the  brain  than  for  the 
cord)  : 

(a)  Pachymeningitis. 

{b)  Gummy  tumor. 

{a)  Pachijmeningitis. — Syphilitic  pachymeningitis  is  found  most 
commonly  over  the  convex  surfaces  of  the  hcmis^iheres,  or  at  the  an- 
terior portion  of  their  base,  in  the  region  of  the  sella  turcica.  It  con- 
sists of  a  diffuse  thickening  of  the  dura  mater,  of  the  outer  layer  of 


LESIONS   OCCASIONING   NERVOUS   SYMPTOMS.  C65 

the  membrane  (endocranitis),  chiefly  in  connection  with  bony  lesions  ; 
of  the  whole  tliickncss  of  the  membrane  ;  or  mainly  of  the  internal 
layer,  usually  coinciding  with  alternations  of  the  pia  mater  and  brain- 
substance.  On  the  surface,  or  in  the  thickness  of  the  dense,  adherent, 
roughened,  injected  membrane,  are  usually  found  yellow,  cheesy,  new 
formations,  spread  out  in  layers  or  circumscribed  as  tumors,  varying 
from  the  size  of  a  small  shot  to  that  of  a  nut,  slightly  or  not  at  all 
vascular,  soft  and  gelatinous,  or  tough  and  consisting  of  gummy  de- 
posit, more  or  less  altered  by  organization  or  fatty  metamorphosis. 
Wagner  has  seen  pachymeningitis  of  the  falx  cerebri.  Occasionally, 
but  less  often,  the  pia  mater  and  arachnoid  are  alone  affected ;  they 
often  are  so  in  connection  with  disease  of  the  dura  mater. 

(5)  Oummy  Tumor. — Gummy  tumor  of  the  meninges  occurs  in 
connection  with  pachymeningitis  as  the  infiltration  or  tumor  of  yellow 
matter  above  described,  the  deposit  occurring  above,  within,  or  beneath 
the  dura  mater,  or  under  the  arachnoid  in  the  pia  and  brain.  The 
changes  due  to  syphilis  occurring  in  the  membranes  of  the  cord  are 
precisely  similar  to  those  described  for  the  brain — a  diffuse  thickening 
with  deposit  of  gummy  material,  infiltrated'or  in  circumscribed  masses. 
Before  a  gumma  retrogrades  it  may  be  soft,  gray,  pink,  or  organized, 
tough,  fibrous,  white  ;  eventually  it  softens  or  becomes  yellow,  cheesy. 

3.  Lesioxs  of  the  Substance  of  the  Beaix  and  Coed. — These 
occur  in  the  brain  in  two  forms  : 

{a)  Diffuse  syphilitic  encephalitis. 

{b)  Grummy  tumor. 

{a)  SijpMlitic  Encephalitis. — This  affection  is  a  parenchymatous 
inflammation  characterized  by  a  diffuse  new  formation  of  cells  in  the 
connective  tissue  of  the  brain.  A  large  extent  of  substance  may  be 
involved,  or  only  a  limited  portion.  Syphilitic  encephalitis  is  often 
described  as  softening  or  as  induration.  Both  forms  occur  separately 
or  combined.  The  newly-formed  connective  tissue  contracts,  occasion- 
ing sclerosis,  and  such  a  sclerosis  may  break  down  centrally,  or  soften 
in  totality.  The  same  lesion  occurs  in  the  cord,  but  whether  dissemi- 
nated sclerosis  of  the  cord,  or  sclerosis  of  the  posterior  gray  matter, 
or  disease  of  the  lateral  or  anterior  columns,  can  be  due  to  syphilis,  is 
still  under  discussion.  Whether,  for  instance,  true  locomotor  ataxia 
is  ever  due  to  syphilis  as  a  cause  is  not  finally  demonstrated,  although 
in  my  opinion  the  weight  of  testimony  is  in  favor  of  the  fact.  Certain 
it  is  that  locomotor  ataxia  occurs  more  often  in  syphilitics  than  in 
others ;  and  equally  certain  is  it  that  ataxic  symptoms  occurring  in 
syphilitic  subjects,  if  attacked  early  and  vigorously  treated,  often  re- 
ceive improvement — sometimes  practically  recover.  And  this  is  not 
the  case  with  non-specific  locomotor  ataxia,  so  far  as  I  know  it. 

Local  softenings  of  the  brain  may  be  occasioned  in  syphilis  by  the 
obliteration  of  the  cavity  of  an  artery  by  syphilitic  disease  in  its  walls 


666  SYPHILIS  OF  THE  NERVOUS  SYSTEM. 

(Bristowc*).  and  consoquent  cutting  off  of  the  t^ni)ply  of  blood  from  a 
part,  acting  in  the  same  way  as  an  embolus  ;  but,  as  a  rule,  as  Lan- 
cereaux  observes,  softening  of  the  braiji  due  to  syphilitic  encephalitis 
may  be  distinguished  from  softening  dependent  on  arterial  oblitera- 
tion by  the  absence  in  the  latter  of  any  product  of  new  formation. 
The  softening  in  83'])hilitic  encephalitis  is  due  to  the  fatty  metamor- 
phosis of  the  newly-formed  tissue. 

{b)  Gummy  Tumor. — Gummy  tumors  of  the  brain-substance  are 
rare.  It  has  been  even  doubted  (Wilks,  Ileubner)  whether  they  ever 
occur  except  in  connection  with  a  gummatous  process  arising  in  the 
pia  mater  or  in  connection  with  a  surface  tumor.  They  occur  in  the 
cerebrum  and  cerebellum,  chiefly  toward  the  periphery  of  the  cere- 
brum, in  the  anterior  and  posterior  lobes.  They  are  found  of  varying 
sizes,  single  or  grouped,  nearly  always  surrounded,  whether  single  or 
multiple,  by  a  dense  fibrous  envelope.  They  arc  white  or  yellow  in 
color,  of  consistence  either  firm,  cartilaginous,  or  fibrous,  or  soft,  lique- 
fied, or  cheesy,  dejjending  upon  their  age  and  greater  or  less  degree  of 
fatty  degeneration.  Little  masses  of  proliferated  connective  tissue  are 
sometimes  found  along  the  course  of  the  vessels.  Gummy  tumors  are 
subject  to  the  same  retrogressive  metamorphosis  in  the  brain  as  else- 
where. They  soften,  and  may  become  totally  absorbed,  leaving  dense 
fibrous  cicatrices  behind  ;  they  may  calcify,  or  finally,  as  shown  by 
Lancereaux,  the  tumor  may  be  absorbed,  leaving  the  fibrous  envelope 
permanently  patulous  as  a  cyst,  containing  a  serous  fluid,  the  whole 
surrounded  or  not  by  softening.  Such  cysts  are  distinguishable  from 
cysts  the  result  of  apoplectic  effusion,  in  that  the  walls  of  the  latter 
are  impregnated  with  the  coloring-matter  of  the  blood  in  an  amorphous 
or  crystalline  state,  and  from  the  result  of  infarction  by  the  condition 
of  the  arteries.  The  lesions  of  the  substance  of  the  cord,  far  less  fre- 
quent than  those  of  the  brain,  are  yet  anatomically  identical  with 
them  :  sclerosis,  softening,  gummy  tumor. 

It  must  not  be  forgotten,  in  connection  with  the  brain-lesions  due 
to  syphilis,  that  local  effusions  of  blood  from  previously-diseased  ves- 
sels, aneurismal  or  otherwise,  in  the  brain  or  in  the  cord,  are  often 
the  immediate  cause  of  the  startling  symptoms  appearing  suddenly 
during  the  course  of  the  disease.  The  plugging  up  of  an  artery  from 
syphilitic  disease  of  its  coat  often  also  occasions  the  sudden  appear- 
ance of  symptoms. 

4.  Lesioxs  of  the  Ceeebral  Artekies. — Ileubner's  investiga- 
tions in  this  field  have  thrown  new  light  upon  the  pathology  of  those 
forms  of  cerebral  syphilis  in  which,  after  death,  the  older  observers 
found  no  lesion,  and  tlierefore  called  the  disease  cerebral  syphilis 
"sine  materia."  A  modern  pathologist  would  probably  have  found 
the  materia  in  syphilitic  thickening  of  the  arterial  coats,  a  change  not 

*  "Lancet,"  June  15,  18'72. 


SYMPTOMS.  G67 

formerly  looked  for,  and  often  not  at  first  obvious  to  the  unaided  eye. 
Some  of  those  cases  of  death  without  obvious  lesion  occurred  early 
after  infection,  but  such  a  date  does  not  exclude  the  possibility  of 
arterial  disease.  Sharkey*  showed  microscopical  specimens  of  syphi- 
litic disease  of  the  cerebral  arteries  to  the  London  Pathological  Society, 
the  patient  having  died  in  the  seventh  month  after  infection.  At  the 
same  meeting  Hulke  cited  an  analogous  case.  Barlow  f  has  a  case  in 
the  first  year  of  inherited  disease.  It  is  probably  better  to  adopt  this 
theory  than  to  accept  the  only  other  one  possible,  namely,  that  there 
has  been  a  passing  congestion  capable  of  causing  death  but  leaving  no 
physical  sign  behind.  TarnowskyJ  quotes  a  case  of  Engelstedt's, 
where,  six  months  after  chancre,  left  hemiplegia  and  aphasia  due  to 
syphilis  came  on  and  terminated  fatally.  At  the  autopsy  the  only 
lesions  found  were  slight  meningeal  hyperaamia  and  a  little  bloody 
serum  in  the  ventricles,  showing  that  ordinary  meningitis  may  come 
on  during  syphilis,  perhaps  being  caused  by  it.  The  changes  occur- 
ring in  the  arteries  due  to  syphilis,  the  possibility  of  occlusion  of  their 
lumen  by  peripheral  thickening,  of  aneurism,  and  of  splitting  of  their 
walls,  atheroma,  etc.,  have  been  discussed  when  considering  the  sub- 
ject of  syphilis  as  affecting  the  vascular  system, 

Symptoms  of  syphilis  of  the  nervous  system  are  of  the  most  varied 
character.  For  practical  reasons  it  is  better  in  a  work  like  the  present 
to  describe  the  various  maladies  rather  than  to  attempt  a  systematic 
display  of  the  symptoms  which  customarily  attend  the  various  lesions. 
In  a  general  way  it  may  be  said  that  arterial  disease,  alone  or  compli- 
cated, is  the  most  common  pathological  condition  of  the  brain  due 
to  syphilis,  and  that  in  arterial  disease  (uncomplicated)  there  is  no 
attendant  optic  neuritis  and  no  paralysis  of  special  nerves.  Night 
pains  in  the  head  may  be  looked  for,  and  sudden  hemiplegia  without 
loss  of  consciousness  is  the  most  common  symptom,  with  more  or  less 
premonitory  warning  in  the  way  of  j)artial  paralytic  or  weak  attacks, 
perhaps  numbness  or  tingling  on  the  side  to  be  affected  ;  giddiness  is  a 
not  uncommon  premonitory  sign.  When  loss  of  consciousness  attends 
a  paralysis  due  to  arterial  disease,  it  is  probable  that  a  vessel  has  given 
way  at  an  aneurismal  or  weakened  point,  and  that  there  has  been  a 
true  apoplexy.  Bone-lesions  and  pachymeningitis,  lesions  next  in  fre- 
quency, are  more  likely  to  be  attended  by  intense  localized  pains,  ojatic 
neuritis,  paralysis  of  special  nerves  and  special  neuralgias,  mental 
changes,  hebetube,  convulsions.  In  the  case  of  gummy  tumor  the 
customary  signs  of  tumor  may  be  present,  optic  neuritis  is  most  com- 
mon, pain  in  the  head  quite  usual,  convulsions,  if  the  tumor,  as  is 
usually  the  case,  lies  near  the  surface,  paralysis  coming  on  gradually, 
and  psychical  phenomena  of  various  kinds. 

*  "Lancet,"  January  20,  1883,  p.  99.  f  "Trans.  Path.  Soc,"  vol.  xxviii,  p.  287. 

X  "  Aphasie  syphilitique,"  Paris,  1870. 


G68  SYniiLis  OF  the  nervous  system. 

As  to  what  symptoms  may  be  caused  by  sypliilis,  it  may  bo  stated, 
judging  from  their  number  and  variety,  that  there  is  probably  no 
symptom  of  any  known  nervous  mahidy,  functional  in  character  or 
due  to  an  organic  cause,  which  may  not  be  occasioned  by  syjjhilis.  In 
describing  the  different  paralyses,  mania,  etc.,  due  to  syphilis,  it  will 
be  noticed,  however,  that  they  usually  have  certain  characteristics 
which  distinguish  them  from  the  same  affection  due  to  other  causes, 
Browu-Sequard  has  justly  remarked  that  the  disorderly  grouping  of 
nervous  phenomena  should  lead  us  to  interrogate  syphilis  as  a  cause  : 
as,  paralysis  of  some  muscle  of  the  eye  and  parajilegia  ;  or  paralysis  of 
one  hand  and  the  other  foot,  etc.  Thus  the  symptoms  may  be  purely 
paralytic,  general,  or  localized  (hemiplegia,  squint),  or  functional 
(aphasia,  bulimia — Fournier),  or  intellectual  (insanity),  or  all  may 
be  combined.  Then  there  may  be  merely  an  emotional  disturbance, 
shown  by  a  tendency  to  laugh  and  cry  from  insufficient  cause,  to 
become  gloomy  and  despondent,  occasionally  exalted,  to  show  great 
peevishness  and  irascibility  in  jolace  of  former  sweetness  of  disposition, 
to  get  hypochondriacal  and  hysterical,  to  evince  dullness  of  perception, 
to  lose  memory,  talk  slowly,  accept  ideas  with  unwonted  deliberation 
and  delay,  and  deliver  them  with  still  greater  slowness  and  lack  of 
vigor.  There  may  be  partial  or  total  hebetude,  and  dementia,  mania, 
acute  or  chronic,  somnolence,  stupor.  Some  of  the  above  mental 
peculiarities  are  almost  certain  to  be  found  in  all  cases  of  physical 
disorder  due  to  brain-syphilis,  but  it  is  chiefly  where  they  occur  alone 
that  they  are  unheeded  and  their  true  cause  overlooked.  A  feeling, 
for  instance,  of  mental  weariness,  a  giving  out  of  the  mind  after  any 
slight  effort  of  the  brain,  such  as  reading  the  daily  paper  ;  inability  to 
think  long  on  any  given  subject  without  a  '•'wretchedness"  and  ''dis- 
tress" in  the  head,  "a  misery,"  as  some  patients  call  it;  symptoms 
of  this  order  have  been  found  to  be  not  at  all  uncommon  with  para- 
lytic and  other  nervous  manifestations  due  to  syphilis,  and  occasion- 
ally to  occur  as  the  only  evidence  of  disease.  All  these  symptoms 
evince  a  lowered  gi-ade  of  nerve-power,  due  to  the  imperfect  vasculari- 
zation of  the  brain  from  syi^hilitic  arterial  disease,  and,  as  they  may 
occur  alone,  their  study  is  of  vast  importance.  They  often  lighten 
up  visibly  as  treatment  takes  effect.  Cases  resembling  in  every  re- 
spect true  hypochondria  (not  syphiliphobia — the  patient  may  never 
suspect  syphilis  to  be  the  cause  of  his  distress),  and  occurring  in 
syphilitic  patients,  frequently  find  relief  only  after  an  antisyphilitic 
course.  An  instructive  case  is  reported  by  R.  W.  Taylor,*  of  this  city, 
of  a  young  married  woman  whom  he  had  treated  for  syphilis  in  1870. 
Fourteen  months  after  her  chancre  she  began  to  have  dull,  supra- 
orbital pain  (not  worse  at  night).  She  was  constantly  troubled  by 
dizziness.     She  walked  unsteadily,  and  felt  as  if  she  must  inevitably 

*  "  Boston  Med.  and  Surg.  Journ.,"  December  24,  1871,  p.  395. 


SYMPTOMS.  6G9 

fall  backward.  Those  vertiginous  feelings  were  prolonged  and  pain- 
ful ;  they  never  went  to  loss  of  consciousness.  iSlie  was  treated  in 
the  country  for  hysteria,  with  no  result.  She  became  sad,  despondent, 
emaciated.  Her  digestive  functions  were  all  normal.  She  was  iras- 
cible and  full  of  emotions  and  abstractions,  dejected,  despondent,  sus- 
picious, imagining  that  her  friends  were  making  fun  of  her,  and  easily 
frightened.  Her  memory  had  become  very  poor.  This  girl  had  never 
been  hysterical  before  the  attack  above  recounted.  Treatment  for 
hysteria  in  the  country,  where  she  was  in  good  hygienic  surroundings, 
was  useless  ;  two  months  of  mixed  autisyphilitic  treatment  in  the  city 
effected  a  cure. 

Another  form  under  which  nervous  syphilis  frequently  goes  unde- 
tected is  that  of  sunstroke.  Many  an,  individual,  seemingly  over- 
powered by  the  heat  on  a  summer's  day,  has  in  fact  had  an  explosion 
of  pent-up  nervous  syphilis,  which  goes  unrecognized,  and  leaves  him 
with  impaired  brain-power,  high  emotional  excitability,  some  loss  of 
memory,  and  perhaps  some  partial  paralysis,  for  all  of  which  the  sun 
gets  credit,  and  no  effort  is  made  to  combat  the  syphilitic  cause. 
Several  cases  of  this  class  have  fallen  under  the  author's  notice.  One 
l^eculiarity,  often  strikingly  evident  in  patients  suffering  from  nervous 
disease  due  to  syphilis,  is,  that  they  are  very  shy,  distrustful,  slow  to 
recognize  that  syphilis  has  anything  to  do  with  their  symptoms.  It  is 
hard  to  elicit  facts  from  them,  and  patient  tact  may  be  required  in 
their  management  to  keep  them  up  to  treatment. 

Great  care  also  is  necessary  in  the  study  of  nervous  syphilis,  to  avoid 
confounding  some  of  the  manifestations  of  severe  nervous  gout  with 
those  of  syphilis.  Between  them  there  exists  a  wonderful  resemblance. 
Thus  cerebral  congestion,  dizziness,  and  vertigo,  perhaps  culminating 
in  aphasia,  irritability  of  temper,  suspicious  tendencies  to  the  extent 
of  mild  illusions,  tendency  to  an  easy  tiring  of  the  brain,  and  the  pro- 
duction of  a  vexed,  distressed  feeling  in  the  head,  local  neuralgia  as  of 
the  sciatic,  numbness  along  the  course  of  certain  nerves,  especially  the 
radial  and  ulnar,  etc. — all  these,  and  many  more  nervous  symptoms, 
are  found  in  cases  of  well-marked  nervous  gout  as  well  as  in  syjDhilis  ; 
and  when,  added  to  this,  it  is  remembered  that  certain  of  the  dry, 
papulo-squamous,  gouty  eruptions,  which  come  chiefly  in  summer, 
are  purple  in  appearance  and  do  not  itch  much,  the  chances  for  an 
error  of  diagnosis  become  greatly  increased.  As  all  of  the  above 
symptoms  may  be  due  also  to  sj^philis,  a  careful  study  of  the  case,  and 
weighing  of  all  evidence  cautiously,  are  necessary  to  establish  a  diag- 
nosis. If  the  symptoms  are  due  to  the  effects  of  the  gouty  poison,  the 
alkaline  and  eliminative  treatment  is  best  adapted  to  overcome  them  ; 
if  to  syphilis,  autisyphilitic  remedies.  The  manifest  improvement 
which  follows  a  correct  diagnosis  in  these  cases  amply  rewards  the 
surgeon  for  the  time  and  trouble  often  required  to  establish  it. 


G70  STPniLIS  OF  THE  NERVOUS  SYSTEM. 

rnoGNOSis  OF  XEKVors  Syphilis. —  It  can  not  positively  be 
afliriued  of  any  given  individual  with  syphilis  that  he  will  never  have 
nervous  disease  due  to  his  acquired  diathesis,  yet  the  majority  escape. 
A  certain  percentage  suffer,  and  there  docs  not  seem  to  be  any  con- 
trolling diathesis  which  directs  syphilis  toward  the  brain,  unless  possi- 
bly the  gouty.  Severe  cases  of  the  disease,  where  ulcers  destroy  the 
tissues  and  the  bones  decay,  not  unfrequently  escajic  any,  even  the 
faintest,  manifestations  of  nervous  disease.  Others,  dying  of  syphi- 
litic cachexia,  with  perhaps  gummy  tumors  in  most  of  their  internal 
organs,  may  never  lose  power  in  a  single  muscular  fiber,  or  fail  in 
sensation,  or  falter  in  intelligence,  consciousness,  or  speech,  and  yet 
either  of  these  type  cases  may  have  nervous  syphilis  severely  or  lightly. 
On  the  other  hand,  the  mildest  case  Avhicli  may  have  been  untreated, 
or  have  undergone  a  treatment  for  a  while,  may  come  down  suddenly 
■with  any  of  the  forms  of  nervous  disease  at  a  short  (more  commonly 
a  long)  period  after  his  chancre.  Indeed,  Broadbent  *  maintains  that 
it  is  chiefly  where  secondar}'  symptoms  are  light  or  absent,  or  where 
tertiary  symptoms  arrive  very  early  in  the  course  of  the  disease,  that 
nervous  symptoms  are  to  be  expected,  and  be  cites  Gros  and  Lance- 
reaux,  Braus,  Buzzard,  and  Moxon,  in  corroboration  of  his  oi)inion. 
Fournier  has  published  some  cases  going  to  show  that  a  mild  begin- 
ning in  syphilis  furnishes  no  guarantee  that  the  end  will  be  mild,  and 
1 1  have  added  some  testimony  in  the  same  direction.  Yet  from  this 
it  can  not  be  understood  that,  because  the  beginning  of  syphilis  is 
mild,  therefore  the  end  wnll  be  severe  ;  on  the  contrary,  most  cases  that 
commence  as  mild  attacks  so  remain  ;  but  it  can  be  said  that  a  mild 
beginning  does  not  guarantee  a  mild  course  for  the  whole  disease  ;  that 
many  cases  commencing  mildly  are  on  that  account  not  efficiently 
treated  by  a  prolonged  mercurial  course  ;  and  that  it  is  jDOSsibly  on  this 
account  that  some  of  the  mild  cases  ultimately  become  very  severe 
ones. 

An  attempt  has  been  made  to  show  that  injury  to  the  head  or  ex- 
cessive mental  exercise  predisposes  to  the  outbreak  of  brain-disease  in 
the  course  of  syphilis.  I  think  that  these  assumptions  are  entirely 
unfounded.  In  the  vast  majority  of  cases  of  cerebral  syphilis  no  his- 
tory of  injury  to  the  head  exists,  and  nervous  phenomena  due  to  syphi- 
lis occur  as  frequently  among  the  laboring  peoijle  as  in  those  devoted 
to  intellectual  pursuits. 

According  to  my  belief,  there  are  four  conditions  which  increase 
the  tendency  to  an  appearance  of  brain  symptoms  during  the  course  of 
syphilis  :  they  are  the  rheumatic  diathesis,  inherited  tendency  to  brain 
troubles,  abuse  of  alcohol,  and  failure  to  take  a  sufficiently  thorough 
and  prolonged  mercurial  course  during  the  earlier  stages  of  syphilitic 
disease. 

*  "  Lancet,"  1874,  Nos.  2-6.  f  "  Trans.  Int.  Med.  Cong.,"  Philadelphia,  1877. 


PROGNOSIS— GENEKAL  TEEATMENT.  071 

But  this  statement  does  not  cover  all  cases.  That  syphilis  attacks 
the  brain  in  some,  but  lets  others  escape,  we  know ;  but  why  it  does 
so  we  do  not  know.  Irregular  or  injudicious  treatment  has  undoubt- 
edly sometliing  to  do  with  the  development  of  nervous  disease,  but 
does  not  necessarily  occasion  it.  The  prognosis,  however,  is  good  in 
proportion  as  the  manifestation  is  near  in  point  of  time  to  the  chancre, 
and  in  proportion  as  intelligent  treatment  is  speedily  brought  to  bear 
upon  the  case.  The  lightest  cases,  untreated  or  treated  too  late,  may 
result  in  permanent  functional  disturbance. 

In  any  case,  and  as  a  general  rule,  no  symptoms  of  nervous  syphi- 
lis, however  alarming,  need  necessitate  a  fatal  prognosis,  especially  if 
treatment  has  not  yet  been  pushed  ;  some  cases  seem  almost  to  rise  out 
of  the  grave  under  the  influence  of  the  iodide  of  potassium.  Always 
with  a  given  symptom,  the  prognosis  is  better  if  syphilis  can  be  made 
out  as  a  cause,  than  if  any  other  disease  or  lesion  has  occasioned  it. 
Many  cases  of  obscure  brain-disease,  which  are  benefited  by  the  iodide 
of  potassium,  are  undoubtedly  unrecognized  remains  of  old,  perhaps 
forgotten,  syphilitic  poisoning. 

The  vast  majority  of  cases  occur  late  in  the  disease  ;  others,  appear- 
ing early,  are  manifested  and  promptly  benefited  by  mercury,  as  are 
probably  all  cases  where  the  lesion  is  not  purely  gummatous.  Nervous 
symptoms  due  to  syphilis  are  found  in  inherited  as  well  as  in  second- 
ary and  tertiary  disease. 

General  Treatmen"t  of  Nervous  Syphilis. — In  the  treatment 
of  nervous  syphilis,  the  delicate  nature  of  the  tissue  involved  must 
always  be  borne  in  mind.  The  greater  the  promptness  of  action,  the 
more  eflBcient  the  treatment.  In  the  forms  occurring  early  after  chan- 
cre, mercury  alone  will  sometimes  cure,  but  it  ought  not  to  be  relied 
upon.  The  combination  of  the  iodide  does  no  harm  and  may  do  a 
vast  amount  of  good,  and  the  patient  should  have  the  benefit  of  the 
doubt.  Could  we  decide  with  certainty  in  a  given  case  that  the  lesion 
was  purely  gummy,  the  iodide  alone  would  be  all-sufficient,  but,  as 
more  or  less  pachymeningitis  and  arterial  disease  may  be  inferred  to 
exist  in  most  cases,  it  is  better  to  adopt  for  nervous  syphilis  a  mixed 
treatment,  with  the  iodide  largely  in  excess.  It  is  the  latter  agent 
which  most  quickly  controls  the  symptoms  in  desperate  cases,  not  in 
mincing,  therapeutic  doses,  but  in  specific  doses  of  gr.  x-xxx,  com- 
mencing at  which  the  remedy  should  be  run  up  as  rapidly  as  the 
stomach  will  bear  it,  until  the  symptoms  are  stayed  and  forced  into  a 
retreat.  This  result  may  be  confidently  counted  upon  in  all  cases 
where  the  diagnosis  is  accurate,  and  treatment  is  not  commenced  too 
tardily,  and  pushed  too  indolently — if  the  stomach  is  sound.  The 
effect  of  opium  upon  pain  is  not  more  wonderful  or  more  striking  than 
that  of  the  iodide  of  potassium  upon  the  nervous  manifestations  due 
to  syphilis.     In  my  opinion  the  best  treatment  for  all  severe  cases  is 


672  SYPHILIS   OF  TUE  NERVOUS  SYSTEM. 

the  iotlidc  of  potassium  given  in  largo  doses  four  times  a  day,  and  rap- 
idl}'  pushed,  the  vehicle  being,  if  possible,  milk,  or  an  effervescent  al- 
kaline mineral  water  ;  this  combined  with  an  efficient  course  of  mer- 
curial inunction.  Xerve-tissue  can  not  be  reproduced  by  treatment, 
and  often  irre})arable  damage  is  done  to  nerve  cells  and  libers  by  the 
lesions  due  to  syphilis.  Hence  in  many  cases  functional  disorder, 
more  or  less  pronounced,  remains  behind.  In  these  cases  treatment 
can  only  arrest  the  disease,  and  prevent  progress ;  not  rei)lace  nerve- 
tissue  already  destroyed.  Macewen  *  trephined  in  one  case  of  cerebral 
syphilis  with  alleged  good  etl'eet. 

Special  Consideration  of  Nervous  Symptoms  due  to  Si/ji^iiUs. — 
Passing  from  these  general  considerations  of  nervous  disturbances  due 
to  syphilis,  it  becomes  necessary  to  review  the  different  special  dis- 
eases. This  may  bo  more  systematically  done  by  considering  them 
under  three  heads  :  SyiDhilis  of  the  brain,  syphilis  of  the  cord,  and 
syphilis  of  special  nerves. 

Syphilis  of  the  Braix. — Besides  the  aches  and  pains  of  early 
syphilis,  and  the  general  evidences  of  brain-disturbance  affecting  the 
intellect  or  the  emotions,  as  noticed  above,  we  have  to  consider  hemi- 
plegia, epilepsy,  chorea,  general  paralysis,  aphasia,  and  insanity,  all 
liable  to  occur  as  consequences  of  syphilis  affecting  the  brain. 

Si/philitic  hemiplegia  rarely  appears  until  several  years  after  chan- 
cre. It  has  been  occasionally  observed  within  six  months.  Taylor  has 
a  case  at  the  fifth  month,  f  The  attack  may,  but  rarely  does,  come  on 
slowly  ;  it  is  usually  sudden,  and  there  have  been  as  yet  very  few  well- 
authenticated  reports  of  cases  of  syphilitic  hemiplegia  where  there  was 
total  loss  of  consciousness  with  the  attach.  Hence  this  sign  is  of  the 
first  importance.  The  patient  may  be  getting  out  of  bed,  sitting  a 
moment  on  its  edge,  doubting  nothing,  yet  when  he  attempts  to  get 
up  he  pitches  forward  into  the  corner  of  the  room  and  finds  himself 
paralyzed  ;  J  or  lying  by  a  fence  to  shoot  blackbirds,  evidently  perfectly 
well,  when,  endeavoring  to  raise  himself  to  take  aim,  he  may  discover 
that  his  leg  and  arm  are  powerless.*  More  often  the  patient  is  found 
lying  where  he  has  fallen,  unable  to  give  an  account  of  himself,  more  or 
less  completely  hemiplegic,  but  yet  not  unconscious.  Yet  the  attack 
may  be  like  apoplexy  in  all  particulars,  in  loss  of  consciousness  and  in 
the  lesion,  for  a  diseased  vessel  may  give  way,  producing  a  clot  which 
directly  causes  the  symptoms.  With  such  attack  unilateral  paralytic 
(generally)  or  convulsive  phenomena  are  the  rule,  and  often  coincident 
paralysis  of  some  of  the  cerebral  nerves  (ptosis  is  common).  The  lat- 
ter phenomena  often  precede  the  general  attack,  perhaps  by  several 
days ;  hebetude  and  emotional  disturbances  are  common.     Cure  is 

*  "Glasgow  Medical  Journal,"  February,  1884,  p.  142. 

t  "Journal  of  Xervous  and  Mental  Diseases,"  January,  1S7G,  p.  20. 

X  Case  I,  Van  Burcn  and  Kcycs,  op.  cit.  *  Case  III,  ibid. 


EPILErSY.  f)73 

possible,  relapse  to  be  feared.  Several  partial  licmiplcgic  attacks  may 
occur  and  pass  oli"  without  a  true  paralysis,  or  a  linal  severe  attack  may 
leave  the  patient  temporarily  or  permanently  lame.  The  attack  usu- 
ally occurs  before  forty,  and  not  late  in  life,  as  in  hemiplegia  from 
ordinary  causes.  Fixed  headache,  usually  worse  at  night,  generally 
precedes  the  attack  for  several  weeks,  getting  gradually  worse.  Press- 
ure often  increases  this  pain,  although  there  may  be  no  external  evi- 
dences of  disease  upon  the  skull.  The  sensibility  of  the  paralyzed  side 
is  usually  preserved,  or  is  less  affected  than  the  motility,  although  loss 
of  sensibility,  motion  being  i^reserved,  occasionally  occurs.  Paralysis 
of  the  face  sometimes  comes  on  and  lasts  a  few  days  before  the  rest  of 
the  side  suffers  ;  the  leg  or  the  arm  may  be  first  affected,  with  or  with- 
out previous  numbness  or  tingling  of  the  extremities  before  the  attack. 
Vertigo  or  convulsions  confined  to  one  side  not  uncommonly  precede 
the  seizure.  Sometimes  it  takes  a  day  for  loss  of  motion  to  become 
complete.  The  intelligence  is  usually,  indeed  always,  impaired,  the 
emotions  active,  brain-power  low.  Mydriasis,  so  common  with  many 
forms  of  nervous  syphilis  due  to  brain-lesion  (being,  indeed,  a  feature 
of  diagnostic  value,  especially  if  the  patient  be  unconscious  of  its  ex- 
istence, as  is  often  the  case),  accompany  the  attack,  and  long  outlast 
it.     There  may  be  intense  hebetude,  stupidity,  almost  idiocy. 

Hemiplegia  in  a  mild  form,  due  to  syphilis,  may  come  on  and  dis- 
appear rapidly  several  times  without  appreciable  exciting  cause.  If 
treated  early,  such  cases  are  usually  entirely  curable. 

Sypliilitic  epilepsij  occurs  several  years  after  chancre,  but,  like  all 
other  rules  in  syphilis,  this  also  has  many  exceijtions.*  Ordinary  epi- 
lepsy comes  on  before  jDuberty,  the  syphilitic  epileptiform  convulsion 
rarely  before  thirty  ;  the  reason  being  the  same  for  bringing  the  date 
of  epilepsy  late  in  life  as  for  bringing  that  of  syphilitic  hemiplegia 
early  ;  namely,  most  patients  get  syphilis  at  about  the  age  of  twenty. 
The  aura  is  not  necessarily  present  in  syphilitic  epilepsy.  Nocturnal 
attacks  are  not  characteristic  of  it,  as  was  once  thought ;  nor  is  the 
occurrence  of  many  attacks  in  quick  succession,  with  a  long  interval 
of  calm,  necessarily  conclusive.  The  main  symptoms  for  diagnosis 
are  five  : 

1.  Persistent  headache  before  the  attacks,  and  between  them. 

2.  The  age  of  the  patient  when  the  attacks  commenced. 

3.  Aggravation  of  stupidity,  intellectual  distress,  and  general  ma- 
laise, after  the  attacks. 

4.  The  possible  coincidence  of  paralytic  symptoms  with  or  without 
optic  neuritis. 

5.  The  possible  association  of  the  convulsions  with  intellectual  or 
moral  (emotional)  phenomena. 

*  Bumstead  has  recorded  a  case  occurring  a  few  months  after  mfoction,  and  cases 
within  the  year  are  quite  numerous. 
43 


674  SYPHILIS  OF  the  nervous  system. 

Various  spasmodic  seizures  (not  t3'pieally  ejiileptic)  arc  caused  by 
the  cerebral  lesions  of  syphilis.  Unilateral  sjiasm  is  not  very  uncom- 
mon, and  when  coupled  with  other  symptoms,  such  as  oi)iic  neuritis 
(Jackson,  Buzzard),  or  paralytic  or  emotional  or  intellectual  phenom- 
ena, the  cause  is  almost  certain  to  be  syphilis.  The  epileptic  attack- 
not  infrequently  commences  in  a  certain  fixed  way  as  a  uuikateral 
spasm,  possibly  starting  in  tlie  thumb  or  elsewhere,  and  working  up. 
It  may  then  remain  unilateral,  or  l)ecome  general.  The  petit  mal 
is  not  uncommon  in  cases  of  syphilitic  convulsive  disorder,  and  may 
be  attended  by  temporary  loss  of  sight,  vertigo,  loss  of  conscious- 
ness. 

Treatment  often  elTects  perfect  cures,  but  sometimes  what  is  called 
the  epileptic  habit  is  left  behind,  and  the  patient  continues  to  have 
seizures  through  montlis,  perhaps  years. 

Chorea,  catalep!<y,  ami  (jeneral paralysis  have  been  noted  but  very 
rarely  among  the  nervous  diseases  due  to  syphilis.  They  have  none  of 
them  any  special  distinguishing  marks,  except  tlioir  coincidence  with 
other  syphilitic  symptoms,  and  the  fact  that  they  are  curable  by  appro- 
priate treatment. 

To  syphilitic  aphasia  the  same  remarks  apply.  Tarnowsky.*  in  his 
excellent  monograph  founded  on  the  collection  of  fifty-two  cases  of 
syjihilitic  aphasia,  has  failed  to  point  out  any  distinguishing  mark  for 
it,  except  the  concomitant  of  the  syphilitic  diathesis  and  the  possibil- 
ity of  speedy  cure  by  appropriate  medication.  It  is  by  no  means  an 
uncommon  form  of  nervous  syphilis. 

Syphilitic  Insanity. — Many  different  forms  of  mental  alienation 
have  been  observed  upon  syphilitic  patients  often, f  coincidently  or 
alternating  with  other  positive  evidences  of  nervous  syphilis.  Neither 
syphilitic  mania  nor  insanity  has  yet  developed  by  its  history  any  spe- 
cially trustworthy  diagnostic  features.  Coincidence  of  other  troubles, 
nervous  or  physical,  due  to  syphilis,  should  have  weight  in  deciding 
the  treatment,  which  latter  not  uncommonly  produces  wonderful  re- 
sults. In  our  rapidly-advancing  knowledge  of  the  power  of  syphilis 
in  producing  various  forms  of  mental  derangement  it  becomes  obvi- 
ously the  duty  of  those  intrusted  with  the  care  of  the  insane  to  ex- 
amine them  physically  with  care  in  search  of  evidences  of  constitu- 
tional taint.  Perhaps,  the  two  most  valuable  symptoms  to  be  elicited 
on  examination  are  morbid  tenderness  of  the  subcutaneous  surfaces  of 
the  tibiae  and  irregularly  dilated  pupils. 

Syphilis  of  the  Coed. — The  cord  is  less  commonly  the  seat  of 
syphilis  than  the  brain.  The  lesions  affecting  the  cord,  as  already  de- 
tailed, are  disease  of  the  bones  inclosfng  it,  meningeal  thickening,  dif- 
fuse connective-tissue  proliferation  of  the  parenchyma  of  the  cord, 

*  "  Aphasic  sypliilitiqiio,"  Pari;*,  LSYO. 

f  Cases  XXXI  and  XXXIII,  Van  Burcn  and  Keyes. 


SYPHILIS  OF  THE  CORD.  075 

with  hardening  or  spots  of  softening,  and  gummy  tumor.  It  has  not 
yet  been  distinctly  made  out  whether  or  not  locomotor  ataxia  may  be 
directly  due  to  syphilis.  The  matter  is  still  a  question  of  controversy, 
but  the  almost  universal  testimony  is  that  a  majority  of  the  patients 
with  ataxia  and  irregular  ataxic  symptoms  have  had  syphilis,  and 
another  fact  is  not  less  clear,  namely,  that  many  such  patients  derive 
more  improvement  from  a  thorough  antisyphilitic  course  of  medica- 
tion than  through  any  other  means  of  treatment.  There  is  a  vast 
amount  of  literature  and  statistics  upon  this  subject,  but  the  general 
facts  are  as  above  stated,  and  the  natural  deduction  is  that  it  is  only 
just  to  a  patient  with  ataxic  symptoms,  if  a  history  (or  a  suspicion)  of 
old  syphilis  exists,  to  give  him  the  benefit  of  the  doubt,  and  to  ply 
him  vigorously  with  a  thorough  specific  course  of  medication  before 
resorting  to  the  means  commonly  employed  against  ordinary  locomotor 
ataxia.  Cure  can  not  generally  be  obtained,  but  improvement  may  be, 
and  if  the  treatment  is  commenced  early  the  disease  may  at  least  be 
stayed,  as  I  have  witnessed  more  than  once. 

SypMUtic  paraplegia  is  very  rarely  complete.  The  impairment  of 
motion  usually  comes  on  gradually  many  years  after  chancre.  The  ex- 
tremes of  time,  as  observed  by  the  authors,  are  eight  months  and  twenty- 
one  years.*  The  bladder  always  suffers,  sometimes  before  the  general 
attack,  always  during  its  continuance,  and  general  treatment  has  but 
little  effect  over  this  symptom.  The  sphincters  are  rarely,  if  ever,  re- 
laxed. The  expulsive  power  of  the  rectum  is  usually  greatly  dimin- 
ished. Sensation  is  not  affected  as  a  rule.  In  a  few  cases  (Petrequin, 
Zambaco)  there  has  been  loss  of  sensation  in  the  legs  without  loss  of 
motion. 

One  case  of  syphilitic  paraplegia  has  been  observed  by  the  authors 
in  inherited  syphilis,  the  child  being  five  years  old.f  There  is  rarely 
any  complaint  of  pain  in  the  back  while  the  disease  is  coming  on,  but 
it  may  occur,  together  with  numbness  of  the  extremities.  Convulsive 
motions  are  rarely  present.  The  feeling  as  of  a  girdle  around  the  body 
is  quite  common,  but  not  pathognomonic.  The  affection  rarely  comes 
on  until  long  after  all  symptoms,  secondary  and  tertiary,  have  disap- 
peared. Zambaco  J  believes  that  the  only  peculiar  sign  by  which 
syphilis  may  be  distinguished  as  a  cause  of  ]3araplegia  is  rapid  amelio- 
ration under  treatment  commenced  promptly.  Lancereaux  states 
that  incomplete  paraplegia,  with  pain  along  the  nerves  and  contrac- 
tion of  muscles,  indicates  meningeal  lesion  ;  while  complete  para- 
plegia, no  pain,  and  preserved  reflex  motion,  indicate  medullary 
lesion. 

The  intellect  is  usually  sound  with  paraplegia,  but  emotional  irregu- 
larities can  usually  be  detected  on  study.  Paraplegia  does  not  neces- 
sarily imply  that  the  preceding  syphilis  has  been  severe,  and,  although 

•■  Loc.  cit.  f  Case  XXVII,  Van  Burcn  and  Keyes.  X  Op.  cif.,  p.  927. 


(376  SYPHILIS   OF  THE  NERVOUS   SYSTEM. 

one  of  the  latest  affoctions  of  syphilis,  still  the  eight  months' case* 
shows  the  possihility  of  exception. 

Treatment  is  less  effective  in  iiaraplegia  than  in  most  other  nervous 
affections.  Still,  something  can  always  be  gained,  and  a  cure  may  be 
hoped  for,  if  too  much  time  has  not  elapsed  before  treatment  is  com- 
menced ;  often,  where  the  effects  of  disease  can  not  be  removed,  its 
course  may  be  stayed  permanently  by  an  intelligent  course  of  manage- 
ment.    The  bladder  requires  separate  care  (catheter,  injections,  etc.). 

Syphilis  of  Special  Nerves. — Among  the  symptoms  to  be  as- 
cribed to  affections  of  special  nerves  must  be  mentioned  the  facts 
made  out  by  the  patient  investigation  of  Fournier,  of  the  occasional 
existence  (especially  in  women)  of  localized  areas  of  analgesia,  which, 
while  they  may  take  place  on  nearly  all  the  cutaneous  surfaces,  have, 
as  a  point  of  special  election,  the  backs  of  the  hands,  where  pinching 
and  pricking  of  pins  are  often  unobserved  by  patients  so  affected. 
This  perverted  sensibility,  comes  on  early  in  the  secondary  period  of 
syphilis,  and,  if  not  removed  by  treatment,  gets  well  s])ontancously. 

But  there  are  more  positive  symptoms,  due  to  lesions  of  special 
nerves,  requiring  attention.  The  lesions  occasioning  them  are  numer- 
ous— syphilitic  diseases  of  the  long,  bony  canals  through  which  they 
pass,  pressure  from  neighboring  gummy  tumor,  disease  at  the  origin 
of  the  nerve,  thickening  of  the  nerve-sheath,  interstitial  neuritis,  and 
interstitial  gummata.  From  some  of  the  above  causes  single  muscles 
or  groups  of  muscles  anywhere  in  the  body  may  become  paralyzed,  but 
it  is  impossible  to  systematize  such  lesions  in  a  text-book.  Suffice  it 
to  say,  irregularly  distributed  paralysis  without  a  valid  explanation 
for  its  irregularity  should  always  excite  the  suspicion  of  syphilis.  The 
nerves  most  commonly  affected  are  the  seventh  pair,  the  fifth  pair,  the 
motors  of  the  eye,  and  the  s])inal  nerves.  Lancereaux  believes  that 
the  sympathetic  may  be  specially  involved,  and,  although  there  is  no 
reason  to  the  contrary,  still  nothing  is  absolutely  proved  in  this  direc- 
tion. The  nerves  of  special  sense  do  not  always  escape.  The  sense  of 
taste  is  rarely  injured,  except  by  such  ravages  as  destroy  the  palates 
(when  smell  and  taste  are  both  defective),  and  occasionally  Avhere  the 
tongue  is  the  seat  of  syphilitic  tumor  (Zambaco).  The  sense  of  smell 
suffers  in  all  the  syphilitic  necroses  of  the  bones  of  the  nose,  especially 
where  the  ethmoid  is  involved.  AVitli  pachymeningitis  about  the  base 
of  the  anterior  cerebral  lobes  the  olfactory  bulbs  may  be  involved.  In 
such  cases  sight  is  pretty  sure  to  suffer  as  well  as  the  sense  of  smell. 
Sight  may  be  impaired  by  gummy  exudation  in  various  situations, 
neuritis,  etc.  Galezowski  f  believes  that,  where  the  optic  nerve  is  in- 
volved previously  to  its  entry  into  the  globe,  sight  is  defective  in  both 
eyes.  Many  of  the  troubles  of  vision  due  to  syphilis  depend  upon 
syphilitic  changes  in  the  media  themselves  of  the  eyes  (see  Chapter 

*  Case  VI,  Van  Burcn  and  Keyes.  f  "  Gaz.  dcs  n6p.,"  1866,  p.  106. 


SYPIIILLS   OF   SPECIAL   NERVES.  f577 

VIII).  Deafness  may  also  be  found  to  depend  upon  sypliilis.  Some- 
times it  is  transitory,  occurring  during  tlie  early  eruptive  stages,  or  it 
comes  on  late  in  the  disease,  due  to  syphilitic  affection  of  the  bones  of 
or  around  the  ear,  or  destructive  ulceration  of  the  pharynx  implicat- 
ing tlie  Eustachian  tube  (see  Chapter  IX),  or  to  disease  implicating 
the  portio  mollis. 

Third  Nerve. — The  nerves  of  the  eyes  are  frequently  involved  in 
syphilis  (see  Chapter  VIII).  Of  all  nerves,  the  third  suffers  most  fre- 
quently. Its  early,  paralysis  may  occur  in  the  exanthematic  stage  of 
the  disease,  but  this  form  soon  gets  well,  and  is  unimportant.  Later 
on  it  indicates  more  serious,  usually  cerebral  disease.  Its  main  symp- 
toms are  ptosis,  divergent  strabismus,  and  mydriasis.  Of  these,  the 
latter  is  the  slowest  to  disappear.  Where  there  is  disease  of  the  optic 
nerve  or  the  retina,  mydriasis  may  be  the  effect  of  lack  of  sensitive- 
ness of  the  latter  to  light ;  but,  where  the  eye  is  healthy,  and  mydria- 
sis occurs,  syphilis  is.  often  to  blame.  Victor  de  Meric  has  given  some 
instructive  cases.*  If  there  is  only  mydriasis,  without  any  other  evi- 
dence of  disease  in  the  third  nerve,  it  is  believed  that  only  the  short 
ciliary  branches,  coming  from  the  fore-part  of  the  lenticular  ganglion, 
are  the  seat  of  the  lesion.  Hutchinson  f  has  made  an  admirable  con- 
tribution to  our  knowledge  of  the  muscular  troubles  of  the  eye  due  to 
syphilis.     Myosis  has  been  observed  (without  iritis)  :  Tuke,J  Tait.* 

These  symptoms,  ptosis,  squint,  and  mydriasis,  especially  the  latter, 
are  not  usually  found  alone,  but  accompany  some  of  the  other  more 
considerable  evidences  of  syphilitic  nerve-trouble.  They  are  all  sus- 
ceptible of  cure  under  treatment. 

Foiorth  Pair. — Graefe,  who  attributed  ''nearly  half"  the  cases  of 
paralytic  trouble  he  met  with  about  the  eye  to  syphilis,  has  rei^orted 
one  case  of  syphilitic  paralysis  of  the  i^atheticus  (see  Chapter  VIII), 
the  symptoms  being  double  vision,  with  one  image  above  the  other.  || 
The  authors  have  seen  one  similar  case. 

Fifth  Pair. — The  syphilitic  affections  of  this  nerve,  in  a  mild  de- 
gree, are  sufficiently  numerous.  Neuralgia  of  one  or  all  the  branches 
of  the  nerve  is  usually  the  symptom,  more  rarely  hypersesthesia  or 
anaesthesia.  These  symptoms  may  come  early,  and  are  then  easier  of 
relief  ;  later,  with  other  evidences  of  severe  nervous  syphilis,  they  are 
not  so  manageable,  but  still  they  yield  more  or  less  good  results  to  the 
intelligent  use  of  the  iodide. 

Sixth  Pair. — Paralysis  of  this  nerve  is  quite  rare.  Follin  says  that 
sharp  pains  around  the  orbit  usually  precede  it.     Symptoms  are,  double 

*  "British  Medical  Journal,"  ISYO,  pp.  29,  52 — cases  of  syphilitic  affection  of  the 
third  nerve  producing  mydriasis,  with  and  without  ptosis. 

t  "  Medico-Chir.  Trans.,"  18'79,  p.  303.  %  "Journ.  Mental  Sci.,"  October,  1874. 

*  "Brit.  Med.  Journ.,"  1870,  pp.  29,  52. 

II  "Archiv  fiir  Ophthalmologie,"  Bd.  i,  2,  pp.  313-318. 


678  SYPHILIS   OF   THE   NERVOUS  SYSTEM. 

vision  aiid  converging  strabismus.  Treatment  often  will  cure  such 
cases,  an  operation  will  not. 

Sevenfh  Pair. — Paralysis  of  the  facial  nerve  is  not  uncommon,  and 
is  interesting  both  on  account  of  its  liability  to  ajjpear  early  in  the 
disease,  within  a  few  weeks  after  infection,  and  from  the  fact  that  it 
sometimes  precedes  hemiplegia  by  several  days,  announcing  it  as  it 
were.  When  facial  paralysis  due  to  syphilis  occurs  alone,  not  con- 
nected with  other  manifestations  of  profound  nervous  disease,  it  is 
liable  to  come  early.  Bassereau  and  Vidal  do  Cassis  have  each  re- 
corded two  cases  within  the  first  few  weeks  after  infection.  Van  Bu- 
ren  and  Keyes  have  reported  a  case  *  during  the  second  month.  Alrik 
Ljunggrun  f  gives  several  others,  occurring  alone  and  quite  early  in 
the  general  malady.  Many  other  cases,  coming  on  during  the  first 
few  months,  might  be  cited.  These  early  paralyses  are  mild,  there  is 
rarely  any  pain,  and  they  tend  to  get  well  quickly,  under  the  continu- 
ance of  ordinary  antisyphilitic  treatment  appropriate  to  secondary 
disease.  The  variety  that  occurs  late  is  more  apt  to  be  occasioned  by 
some  severe  lesion  of  the  bone,  brain,  or  nerve,  and  its  removal  is  gen- 
erally difficult  and  slow.  When  occurring  late  in  syphilis,  facial  paraly- 
sis is  but  one  of  a  group  of  phenomena,  paralytic,  intellectual,  and 
emotional,  with  a  general  train  of  forerunning  and  accompanying 
symptoms,  such  as  has  been  already  traced,  antecedent  pain,  amnesia, 
emotional  excitability,  etc.,  etc.  The  attack  may  be  sudden,  or  slowly 
lU'ogressive,  jjainful  or  not,  perhaps  followed  by  hemiplegia.  It  is 
rare  for  both  facial  nerves  to  suffer  at  the  same  time. 

The  hypoglossal  nerve  suffers  from  syphilis,  as  llughlings  Jackson  J 
first  showed.  The  glosso-pharyngeal  and  pneumogastric  have  not  been 
reported,  so  far  as  I  know  ;  the  spinal  accessory  has,  but  it  is  quite  evi- 
dent that  no  nerve  in  the  body  is  certainly  free  from  possible  implica- 
tion by  syphilitic  disease. 

Spinal  ISTeryes. — Local  neuralgias,  ansesthesia,  analgesia,  paraly- 
ses, contractions  and  wasting  of  groups  of  muscles,  are  the  symptoms 
characterizing  lesions  of  special  spinal  nerves,  such  lesions  being  within 
or  without  the  vertebral  canal.  Sciatica,  pleurodynia,  etc.,  occurring 
during  syphilis,  and  getting  well  under  antisyphilitic  treatment,  are 
not  very  uncommon.  Atrophy  of  single  muscles  or  groups  of  muscles 
affected  with  syphilitic  paralysis  is  more  rare.* 

*  Case  V,  loc.  cit. 

f  "  Klinische  Beobachtungen  iiber  Visceral-Syphilis."  "  Archiv  f  iir  Dcnu.  unci  Syphil.," 
No.  2,  1870,  p.  141. 

X  Bughlings  Jackson,  "Lond.  nop.  Rpts.,"  vol.  iv,  p.  319. 

*  Case  XIX,  Van  Buren  and  Keyes,  is  an  example  in  point. 


DATE   OF   APrEARANCE.  079 


CHAPTER  XIII. 

INHERITED  SYPHILIS. 

Inheritance  from  either  Parent,  the  other  remajning  sound.— Abortion  due  to  Syphilis.— Date  of  Ap- 
pearance of  Symptoms.— Symptoms.— Visceral  Syphilis.— The  Syphilitic  Countenance.— Treat- 
ment of  Inherited  Syphilis. 

Syphilis  may  be  acquired  by  a  hcaltby  baby  from  nursing  a  woman 
with  chancre  or  mucous  patches  of  the  nijiple,  or  through  vaccination, 
or  by  coming  into  contact  with  lesions  yielding  the  virus,  in  a  manner 
capable  of  having  the  poison  absorbed  through  an  abraded  surface. 
When  so  acquired,  the  disease  is  essentially  the  same  as  in  the  adult, 
and  is  called  infantile  syphilis.  Such  disease  is  often  very  active,  even 
fatal.  When  syphilis  is  inherited,  however,  its  course  and  symptoms 
are  modified.  SyiDliilis  may  be  inherited  from  a  mother  who  has  had 
the  disease  but  does  not  at  the  time  aj)pear  to  be  suffering  from  its 
symptoms  ;  or,  again,  if  she  become  infected  at  the  moment  of  impreg- 
nation, or  during  gestation  up  to  the  end  of  the  seventh  month,  after 
which  time,  according  to  Diday,  the  child  escapes.*  Some  of  the 
problems  of  inherited  syphilis  are  still  undecided.  They  are  for  the 
clinical  observer  to  solve.  It  is  not  possible  yet  to  speak  with  absolute 
certainty  about  some  of  them. 

Abortion"  due  to  Syphilis. — A  syphilitic  woman  usually  aborts. 
If  no  treatment  be  employed,  abortions  continue,  perhaps  at  later  and 
later  months,  until  finally  a  living  child,  with  inherited  syphilis,  is 
produced.  When  a  woman  who  is  distinctly  syphilitic  becomes  preg- 
nant, a  continuous  mild  mercurial  course  ofi:ers  her  the  best  chance  of 
bringing  a  living  child  into  the  world.  The  causes  of  abortion  do  not 
seem  to  lie  in  syphilitic  disease  of  the  womb,  but  in  a  blasting  of  the 
vitality  of  the  foetus,  through  visceral  syphilitic  disease,  and  through 
fatty  degeneration  of  the  placenta  (Barnes). 

Date  of  Appearance  of  Symptoms. — The  date  at  which  the 
syphilitic  poison  may  manifest  itself  in  an  infant  who  has  inherited  it 
is  variable.  The  germ  may  be  blighted,  and  early  or  late  abortion 
ensue  ;  the  child  may  come  into  the  world  covered  by  an  eruption  and 
with  advanced  syphilis  of  the  liver,  lungs,  etc.  Often,  however,  the 
child  is  born  seemingly  healthy,  but  fails  to  gain  weight,  and  develops 
an  eruption,  with  snuffles,  etc.,  somewhere  during  the  third  or  fourth 
week.  It  may  be  two  or  three  months  before  positive  signs  appear, 
but  this  is  rare,  and  much  more  uncommon,  though  still  possible,  is 

*  This  subject  has  already  been  discussed  at  some  length  under  the  head  "  The  Methods 
of  Transmission  of  Syphilis,"  p.  510  et  seq.,  and  to  this  section  the  reader  is  referred. 


680  INHERITED  SYPHILIS. 

the  lapse  of  several  years  before  symptoms  come  on.  Cases  are  not 
very  infrequently  encountered  where  a  grooving  or  full-grown  child 
first  presents  evidences  of  syphilis,  the  disease  being  unmistakably  in- 
herited, perhaps  the  father  known  to  be  syphilitic,  yet  neither  the 
child  nor  the  mother  can  be  brought  to  confess  directly  or  indirectly 
any  antecedent  syphilitic  disease.  That  tliere  may  have  been  some 
undiscovered  symptom  in  babyhood  must  be  allowed,  but  still  it  is  as 
near  a  certainty  as  possible,  without  absolute  proof,  that  a  child  of  a 
parent  whose  syphilis  has  nearly  run  out  may  show  no  signs  of  disease 
until  many  years  after  birth,  and  then  the  lesion  will  be  of  a  bone,  a 
joint,  a  gland,  the  eye,  or  perhaps  there  will  be  a  patch  on  the  mucous 
membrane  of  the  buccal  cavity,  an  ulcer  of  the  nose  resembling  lupus, 
or  some  other  single  localized  lesion,  usually  passing  undiagnosticated 
as  far  as  its  etiology  is  concerned.  These  symptoms  were  often  desig- 
nated by  the  older  surgeons  by  the  somewhat  vague  term  of  ''stru- 
mous," as  evincing  characteristics  which  were  not  absolutely  identical 
with  those  of  scrofula.  The  popularity  of  Astley  Cooper's  Avcll-known 
tonic  for  struma  in  early  childhood  (corrosive  sublimate  in  Iluxham's 
tincture  of  bark)  is  possibly  explained  in  this  manner.  Atkinson  *  has 
called  attention  to  the  late  appearance  of  the  symptoms  of  inherited 
disease,  and  their  liability  to  be  confounded  witli  scrofula.  Foiirnier  \ 
has  very  recently  contributed  greatly  to  our  knowledge  of  this  subject 
in  a  colossal  volume. 

Symptoms  of  Ixheeited  Syphilis. — A  child  born  with  inherited 
syphilis  often  manifests  no  evidences  of  the  disease  at  the  time,  unless 
it  be  that  he  has  more  of  the  weazened,  old-man  look  and  dried-up 
appearance  than  is  common  with  babies  at  birth.  This  condition  may 
hold  for  several  weeks  or  months  before  eruptions  ai)pcar.  The  in- 
fants in  the  mean  time  do  not  take  on  flesh,  they  continue  thin,  the 
skin  becomes  more  sallow,  dr}',  and  wrinkled,  they  look  bloodless  and 
mummified,  the  eyes  seem  large,  and  the  expression  is  one  of  aged, 
unearthly,  half-idiotic  intelligence. 

Before  affairs  have  reached  this  pass,  the  junction  of  the  skin  with 
the  mucous  membrane  at  the  different  mucous  orifices  usually  begins 
to  show  some  signs  of  disease.  Fissures,  chaps,  excoriations,  mucous 
patches,  ulcers,  appear  about  the  lips,  in  the  mouth  and  throat,  at 
the  edges  of  the  nose,  around  the  anus,  genitals,  buttocks,  groins, 
axilla?,  umbilicus,  etc.  The  child  gets  the  snuffles ;  its  nose  first  runs, 
and  then  becomes  stopped  up  by  the  swelling  of  the  membrane  and  the 
collection  of  mucus,  pus,  and  blood.  If  the  nose  is  entirely  stopped, 
nursing  is  interfered  with.  The  disease  may  go  on  in  bad  cases  to 
ulcerative  destruction  of  the  cartilages  and  bones  of  the  nose.  This 
nasal  inflammation  sometimes  extends  downward  through  the  pharynx 

*  "Am.  Jour.  Med.  Sci.,"  Jannary,  1879,  p.  71. 
f  "Do  la  Syphilis  bereditairc  tardive,"  Paris,  1886. 


BONES   AND   JOINTS.  C81 

into  the  larynx,  occasioning  a  hoarseness  of  the  cry  often  observed,  in 
syphilitic  children.  Great  or  small  (mucous)  patches  of  livid  excori- 
ation appear  on  the  buttocks,  legs,  and  trunk,  oozing  a  little  thickish 
fluid,  which  partly  scabs  into  a  dark  crust ;  perhaps  these  patches  be- 
come the  seat  of  true  ulceration,  especially  around  the  anus  and  in  the 
o-roin.  Among  the  scabbed  excoriations  and  scattered  patches  may 
appear  a  roseolar  eruption,  the  tint  of  which  is  particularly  livid,  and 
soon  assumes  the  coppery-brown.  Usually  there  are  papules  scattered 
through  the  eruption,  either  small  and  acuminated,  or  broad  and  flat ; 
the  latter  in  convenient  situations,  kept  moist  and  warm  by  being  over- 
lapi^ed  by  skin,  become  mucous  patches.  Papules  appear  by  preference 
about  the  palms,  soles,  and  buttocks.  Subcutaneous  tubercles  are  seen 
in  some  cases.  Pustules  are  not  wanting  in  feeble  children,  but  the 
excoriation  and  mucous  patch  of  the  skin  are  most  common  and  most 
characteristic. 

Infantile pempliigus  is  encountered  in  syphilitic  children.  That  it 
may  occur  from  simple  cachexia,  without  any  virulent  cause,  has  been 
hotly  contended,  and  is  exceptionally  correct,  but  it  is  vastly  more 
common  to  find  it  upon  syphilitic  subjects.  It  indicates  a  bad  tyjoe  of 
disease.  The  child  may  be,  and  not  infrequently  is,,  born  with  it,  or  it 
may  come  out  with  other  manifestations  of  the  disease  some  days  after 
birth.  It  consists  in  bullae,  varying  in  size  from  a  pin's  head  to  a 
penny — usually  about  as  large  as  a  split  pea — filled  with  sero-pus, 
which  rapidly  becomes  purulent,  situated  upon  a  reddened,  excoriated 
base,  surrounded  by  a  red  areola,  which  latter  is  sometimes  slightly 
thickened  and  raised.  When  the  bull«  burst,  thickish  scabs  with  a 
green  tinge  form,  and  underneath  them  ulceration  goes  on. 

The  palms  and  soles  are  the  favorite  seats  of  syphilitic  pemphigus, 
but  in  bad  cases  the  eruption  spreads  from  these  points  until  it  may 
cover  the  entire  body.  Almost  all  cases  die,  though  occasional  recov- 
eries have  been  noted. 

The  nails  in  children  do  not  suffer  from  syphilis  so  often  as  they  do 
in  adult  life,  yet  they  are  not  exempt.  The  best  description  of  the 
changes  in  the  nails  in  children  is  given  by  Hutchinsou  ;  *  one  or  more 
nails  on  each  hand  split  and  become  dry,  cracked,  jagged.  The  matrix 
may  suppurate,  and  the  nails  be  shed  several  times.  The  affection  is 
very  rare.     It  runs  a  chronic,  obstinate  course. 

The  eyes  of  young  infants  do  not  suffer  very  often,  except  from 
conjunctivitis  in  connection  with  the  coryza. 

The  testicles  usually  escaj^e,  but  may  become  the  seat  of  gummy 
deposit. 

Tlie  hones  and  joints  suffer  in  inherited  syphilis  as  they  do  in  the 
acquired  disease,  but  there  are  some  special  forms  of  inherited  syphi- 
litic bone-disease  which  have  received  much  attention  of  late  years, 

*  "  Pathological  Transactions,"  vol.  xii,  p.  259. 


GS2  INHERITED   SYrillLIS. 

imd  have  been  cxliaustivcly  stiulictl,  notably  by  Parrot,  Wcgnor,  Wal- 
ileyer  and  Kobnor,  Cornil,  Barlow,  and  in  this  country  by  Taylor. 
The  tirst  intimations  that  cjiipliy.-^eal  bonc-discasc  in  the  infant  was 
due  to  syphilis  came  from  Yalleix*  in  1834,  and  Boucluitf  in  1861. 
The  first  serious  study  of  bone  syphilis  in  inherited  disease  was  by 
"Wegner  J  in  18^0.  The  most  profound  worker  in  the  Held,  and  he 
who  has  contributed  most  to  our  knowledge  of  the  subject  in  many 
communications  and  essays,  is  Parrot.*  Bone-lesions,  similar  to  those 
of  inherited  syj^hilis,  have  occasionally  been  observed  upon  the  young 
child  whose  disease  has  been  acc^uircd  :  lioger,  I  Taylor.*^ 

The  bony  structures  and  the  epiphyseal  cartilages  of  the  long  bones 
suffer  very  frequently  in  inherited  syphilis — more  often,  says  Parrot, 
than  any  other  structure  except  the  skin.  The  changes  sometimes 
occur  in  intra-uteriiie  life,  sometimes  a  few  weeks  after  birth  ;  Taylor 
says  most  commonly  six  weeks  for  the  epiphyseal  troubles,  or  they  may 
be  delayed  and  first  show  after  the  child  is  two  or  three  years  old,  but 
this  is  more  uncommon.  All  the  bones  of  the  skeleton  may  be  in- 
volved, but  this  is  very  rare.  The  long  bones  and  the  Hat  bones  of  the 
cranium  come  first,  then  the  ribs  and  the  irregular  bones.  The  upper 
extremity  is  of  all  x^laces  the  most  often  implicated. 

The  lesions  have  been  grouped  under  two  heads  : 

1.  Osteo-chondritis  (Wegner). 

2.  Osteophytic  Disease  (Parrot). 

1.  Osteo-cJiondritis. — This  form  occurs  at  the  line  of  junction  be- 
tween the  epiphysis  and  the  diaphysis  of  the  long  bones,  notably  the 
humerus  at  its  lower  end,  and  the  radius.  There  may  be  only  liyper- 
trophied  cartilage-cells,  increased  proliferation,  and  premature  ossifica- 
tion. There  may  be  i^remature  sclerosis  of  the  intercellular  hyaline 
cartilaginous  matrix  (fibrillation,  Veraguth),  and  arrest  of  bony  trans- 
formation. Finally,  the  vessels  may  get  choked  by  the  rapid  ])rolifera- 
tion  of  cells  and  premature  ossification,  and  the  calcification  which 
goes  with  it.  Inflammatory  exudation  comes  on,  abscess  may  appear, 
or  fissuring,  and  the  epiphysis  may  separate  partially  or  entirely  from 
the  diaphysis,  amounting  to  fracture — the  pseudo-paralysis  of  Parrot. 
The  naked  eye  can  distinguish  the  morbid  changes  on  section  as  a  red- 
dish or  grayish-yellow  band,  and  the  hardened  prolongations  of  pre- 
maturely calcified  cartilage  are  easily  seen  and  felt. 

The  gelatiniform  process  of  Parrot  is  so  called  on  account  of  its 
appearance,  masses  of  matter  forming  at  the  epiphyseal  line  or  in  the 
diajihysis  of  jelly-like  consistence,  of  rosy  shade  or  yellow  color.     The 

*  "Bull,  de  la  Soc.  Anat.."  Paris,  1834,  p.  169. 
f  "Maladies  dcs  Enfants  nouvcaux-nes,"  1861. 
X  "  Virchow's  Archiv,"  1870,  p.  305. 

*  Fir.st  in  Rrown-Sequard's  "  Archives  de  Phys.,"  1871-72,  I,  iv,  pp.  319,  470,  613. 
I  "Uuion  Med.,"  1865,  p.  249.  ^  "Bone  Syphilis  in  Children,"  1875,  p.  27. 


OSTEOPIIYTIC   DISEASE.  683 

bony  structure  disappears  under  tliis  change,  leaving  a  loose  fibro- 
cellular  network.  True  suppuration  witii  discliarge  externally  is  not 
common,  but  pus  may  form  and  discharge  or  permeate  a  joint. 

Gclatiniform  atrophy  occurs  rarely  in  the  flat  bones  (skull),  com- 
mencing beneatli  the  periosteum,  and  penetrating  more  or  less  deeply, 
giving  to  the  bones  a  worm-eaten  appearance,  on  autopsy  somewhat 
similar  to  that  seen  in  dry  caries  of  the  adult.  The  skull  may  be  per- 
forated as  by  a  punch.  Barlow  and  Lees*  showed,  at  the  London 
Pathological  Society,  a  living  exhibit  of  syphilitic  craiiio-tabcs  due  to 
gclatiniform  atrophy.  By  firm  pressure  through  tlic  scalp  the  bones 
could  be  felt  to  be  thinned. 

3.  Osteopliytic  Disease. — This  form  of  bone  syphilis  has  been  closely 
studied  by  Parrot,  who  makes  two  forms — [a)  the  osteoid,  (5)  the 
spongioid.  This  lesion  occurs  upon  the  long  and  upon  the  flat  bones, 
and  commences  as  a  subperiosteal  inflammation.  The  osteoid  form 
may  change  into  the  spongioid  form.  The  osteoid  may  occur  as  one 
or  several  subperiosteal  layers  of  interlacing  trabeculte  of  bone,  ar- 
ranged more  or  less  perpendicularly  to  the  axis  of  the  bone  to  form 
an  osteophyte  of  varying  thickness,  perhaps  very  moderate,  perhaps 
an  inch  thick,  upon  the  skull.  To  this  osteophyte  the  thickened  peri- 
osteum adheres.  The  osteophyte  is  more  white  and  calcareous  than 
true  bone  on  section,  and  the  line  between  it  and  the  normal  growth 
is  usually  quite  clearly  defined.  The  growth  is  more  brittle  and  fri- 
able than  normal  bone,  and  under  the  microscope  shows  a  disorderly 
structure  of  the  osteoblasts  and  Haversian  systems. 

The  spongioid  or  rachitic  change  is  found  in  older  children  than 
the  osteoid  form.  The  new  growth  is  more  fibrous  and  vascular  (less 
calcific)  ;  in  a  given  osteopliytic  growth  some  of  the  layers  nearer  the 
bone  may  be  osteoid,  those  nearer  the  periosteum  spongioid.  During 
these  formations  in  young  children  the  shaft  of  the  bone  is  not 
changed ;  as  the  child  grows  older  the  shaft  also  takes  on  spongioid 
changes,  and  gets  light  and  porous.  These  osteophytic  growths  occur 
near  the  ends  of  the  long  bones  more  than  in  the  shaft  (notably  the 
lower  ends  of  the  humerus  and  tibia).  This  swelling  of  the  ends  of 
the  long  bones  resembles  rickets,  particularly  so  as  the  porous  bone 
above  often  bends  out  of  shape  from  muscular  action,  and  so  remains 
in  after-life. 

The  osteophytes  of  the  flat  bones  are  most  pronounced  upon  the 
skull,  where  their  point  of  election  is  the  immediate  perijDhery  of  the 
anterior  fontanelle.  At  first  they  are  reddened  lenticular  swellings  on 
the  external  table,  porous  and  spongy,  sometimes  hard,  rarely  smooth 
like  normal  bone.  These  osteophytes  sometimes  grow  enormously. 
They  may  reach  the  frontal  and  parietal  bosses,  covering  the  cranium, 
and  attaining  a  thickness  of  two  or  three  centinietres.     The  sutures 

*  "  Transactions,"  vol.  xxx,  p.  350. 


GSi  INHERITED   SYPHILIS. 

become  solderetl  together,  and  cranial  development  interfered  with. 
The  four  prominences  about  the  bregma  separated  by  a  crucial  furrow 
are  typical  of  inherited  syphilis.  Tiie  premature  soldering  of  the 
sutures  leads  to  prominence  of  the  bregmatic  region,  and  ultin)a(ely  to 
idiocy. 

Spongioid  syphilis  of  the  cranial  bones,  combined  with  constant 
decubitus  upon  the  same  side,  leads  to  cranio-tabes  (says  Parrot)  ;  and 
when  in  the  same  subject  cranial  osteoj)hytes  and  tabetic  perforations 
exist  they  are  always  on  diametrically  oi)posite  sides,  the  latter  being 
upon  the  side  habitually  subjected  to  pressure. 

Symptoms. — The  symptoms  of  bone  syphilis  are  for  the  most  part 
the  physical  signs.  The  more  inflammatory  the  grade  of  the  osteo- 
chondritis, the  more  pain  may  there  be,  with  perhaps  signs  of  rheuma- 
tism. The  extremity  involved  may  lie  listlessly  at  the  side,  as  if  dead 
— the  pseudo-paralysis  of  Parrot.  There  may  be  crepitation  in  some 
instances  between  the  separated  ends  of  the  epiphysis  and  diaphysis, 
and  there  may  be  abscess  and  fistula  at  the  point  involved.  The  thick- 
enings may  be  felt,  the  bones  may  twist  or  break,  respiration  may  be 
interfered  with,  if  a  rib  is  involved.  Fracture  of  a  brittle  bone  is  un- 
common, separation  of  an  epipln'sis  less  so,  bending  of  a  bone  so  com- 
mon in  connection  with  the  enlargements  at  the  epiphyseal  ends  of 
the  long  bones  of  the  extremities,  that  Parrot*  is  inclined  to  conclude 
that  rickets  is  an  ultimate  expression  of  inherited  syj)hilis  ;  but  a  gen- 
eralization so  sweeping  as  this  can  not  be  maintained,  and  it  has  been 
attacked  with  some  vigor  by  i^athologists,  notably  in  England.  Thick- 
ening in  the  course  of  the  long  bones  can  often  be  plainly  detected. 
In  the  humerus,  by  carrying  the  thumb  and  forefinger  down  the  an- 
terior and  posterior  surface  of  the  bone,  a  thickening  can  be  detected 
at  the  lower  end.  The  internal  surface  of  the  tibia  is  the  jmrt  of  that 
bone  most  often  thickened,  near  the  middle  of  the  bone.  The  outer 
or  front  part  of  the  femur  may  be  thickened.  The  costal  cud  of  the 
ribs  suffers  in  a  similar  way,  or  there  may  be  bending  along  the  course 
of  a  rib. 

"When  the  child  is  older,  perhaps  a  year,  the  quadrangular  elevation 
about  the  anterior  fontanelle  may  be  noticed,  four  rounded  promi- 
nences with  a  crucial  depression  between  them. 

Some  of  the  bone-lesions  of  inherited  s^q^hilis  persist  through  life, 
and  bear  witness  upon  the  skeleton  after  death  that  the  individual  was 
syphilitic  at  birth.  Upon  this  evidence,  aided  by  syphilitic  teeth. 
Parrot  f  establishes  the  great  antiquity  of  syphilis,  having  found  signs 

*  "La  Syph.  hereditaire  et  le  Radiitis,"  "  Progros  Med.,"  Xos.  31,  34,  and  38,  1880. 

+  "Rickets  and  Hereditary  Syphilid,"  London  International  Medical  Congress,  1881. 
Medical  Congress  at  Havre,  1877,  "Lcs  Deformations  craniennes  causecs  par  la  Syphilis 
lier6ditaire,"  and  "Une  Maladie  prehistorique,"  "Revue  Scientifique,"  July  22,  1882, 
p.  110. 


VISCERAL  SYPEILIS   IN   CniLDRExV.  085 

of  inherited  syphilis  upon  bones  of  the  cave-dwellers  in  Europe  and 
upon  prehistoric  bones  brought  from  Peru — bones  buried  before  the 
arrival  of  the  Spaniards. 

The  prognosis  of  bone  syphilis  is  grave,  but  recovery  is  quite  pos- 
sible. The  bony  thickenings  remain,  more  or  less  pronounced,  through 
life. 

Visceral  Syphilis  in"  Children". — Of  more  importance  than  the 
lesions  already  alluded  to,  is  the  visceral  syphiHs  of  young  children 
who  inherit  the  disease.  All  the  various  visceral  lesions  met  with  in 
the  adult  in  acquired  disease  are  also  encountered  in  the  infant  inher- 
iting the  malady.  The  nervous  system  displays  the  same  lesions  upon 
the  meninges  of  the  brain  and  cord,  vascular  changes  and  gummatous 
deposits  are  also  met  with,  and  the  various  lesions  occur  in  frequency 
in  the  order  in  which  they  have  just  been  named.  Idiocy  may  be 
added,  from  early  union  of  the  sutures  through  bony  changes  due  to 
syphilis,  and  the  consequent  arrest  in  development  of  the  brain.  Men- 
ingitis comes  in  the  earlier  months,  gummata  not,  as  a  rule,  until 
after  the  tenth  year.  Vascular  disease  is  not  common,  but  has  been 
encountered.  Hydrocephalus  is  believed  to  have  been  caused  by  in- 
herited syphilis.  Epilepsy  is  not  uncommon,  and  the  same  may  be 
said  of  the  various  paralyses.  Syphilitic  chorea  has  been  claimed,  but 
it  is  very  rare.  I  am  not  aware  that  locomotor  ataxia  has  been  noted 
as  due  to  inherited  syphilis,  or  insanity,  mania,  hebetude,  paresis,  but 
doubtless  they  may  occur.  I  have  seen  acute  mania  in  inherited  syj^hi- 
lis.  The  internal  organs  of  children  inheriting  syphilis  suffer,  as  a 
rule,  more  or  less,  notably  the  thymus,  liver,  lungs,  spleen,  less  often 
the  pancreas  and  kidneys.  The  peritonaeum,  intestines,  lymphatic 
glands,  suprarenal  capsules,  do  not  escape.  Indeed,  the  visceral  lesions 
of  inherited  syphilis  are  disproportionately  severe  when  compared  with 
the  acquired  disease,  and  it  is  this  feature  which  makes  inherited  syphi- 
lis so  commonly  fatal. 

The  prognosis  in  inherited  syphilis  is  bad,  just  in  proportion  to  the 
date  of  appearance  of  the  symptoms,  and  the  general  physical  condition 
of  the  child.  Nasal  catarrh,  if  severe  enough  to  hinder  nursing,  vomit- 
ing and  diarrhoea,  as  interfering  with  nutrition  and  indicating  implica- 
tion of  the  liver,  make  the  prognosis  worse.  If  a  child  is  born  with  a 
general  eruption,  death  is  almost  inevitable,  because  in  such  cases  vis- 
ceral lesions  are  quite  certain  to  be  present  in  severe  form.  The  pos- 
sibility of  the  late  appearance  of  the  lesions  and  symptoms  must  not 
be  lost  sight  of.  This  subject  has  already  been  considered  in  the  ear- 
lier pages  of  the  present  chapter. 

The  Syphilitic  Countenance.— To  Mr.  Hutchinson*  the  pro- 
fession is  indebted  for  the  development  of  many  important  and  inter- 

*  "  Means  of  recognizing  the  Subjects  of  Inherited  Syphilis  in  Adult  Life,"  "  Medical 
Times  and  Gazette,"  September,  1858,  p.  263,  and  art.  "  Rejniolds's  System  of  Medicine." 


6SG  INHERITED   SYPHILIS. 

esting  facts  in  conncotion  with  the  subject  of  congenital  sypliilis,  espe- 
cially as  indelibl}-  stamped  upon  tlie  individual  after  his  earlier  child- 
hood. These  appearances,  until  Hutchinson  called  attention  to  them, 
had  either  been  ignored,  unobserved,  or  attributed  to  scrofula.  They 
are  briefly  these  : 

A  child  who  has  inherited  syphilis,  who  perhaps  has  never  shown 
marked  evidences  of  the  disease  in  babyhood,  becomes  somewhat 
blighted  in  his  development.  His  skin  is  coarse,  earthy,  pallid,  per- 
haps showing  cicatrices.  He  has  a  squared  face,  prominent  check- 
bones,  overhanging  forehead,  and  a  sunken  bridge  to  his  nose.  He 
looks  prematurely  old  and  grave,  and  may  have  chronic  catarrh,  inter- 
stitial keratitis,  ulceration  of  the  throat,  or  cicatrices  of  the  mouth  or 
soft  palate.  The  permanent  teeth  are  irregularly  set  and  defective, 
especially  the  two  middle  upper  incisors,  which  Hutchinson  calls  the 
*' test- teeth."  These  are  small,  often  converging,  sometimes  diverg- 
ing. The  cutting-edge  of  the  teeth  is  sometimes  narrowed,  rounded 
off,  whence  the  name  "pegged  teeth."  They  are  stunted  and  badly 
developed,  often  marked  with  seams  (lines,  ridges)  in  front,  and  of  a 
dirty-brownish  color,  but  their  chief  peculiarity  is  found  in  their 
edges,  which,  being  thin  when  cut,  break  off  centrally,  leaving  a 
"broad,  shallow,  vertical"  notch  on  the  lower  border  of  the  tooth. 
This  becomes  smoothed  down  with  advancing  years,  but  the  size  and 
shape  remain  to  indicate  a  blighted  tooth.  Not  all  children  with 
inherited  syphilis  have  these  teeth,  but  many  do,  and  the  sign  is 
well  worthy  to  be  carefully  watched  for.  It  not  infrequently  hajD- 
pens  that  one  child  of  a  family  has  the  notched,  pegged  teeth,  while 
brothers  and  sisters  born  afterward  escape,  yet  still  any  of  these 
latter  may  late  along  in  childhood  develop  some  periosteal  thicken- 
ing, some  indurated  scaly  patch  on  the  skin,  or  mild,  raised,  excori- 
ated, insensitive  patch  of  thickening  on  the  mucous  membrane  of 
the  mouth,  which  the  practiced  eye  and  touch  recognize  as  sy])hi- 
litic,  and  which  melts  away  under  antisyphilitic  treatment,  boldly 
administered. 

The  profession  is  not  entirely  in  accord  upon  the  question  of  syjDhi- 
litic  teeth.  Clearly  syphilis  is  capable  of  disfiguring  the  teeth,  and 
Hutchinson  *  has  clearly  shown  that  the  notched  central  permanent 
incisors  in  the  upper  jaw  justly  enjoy  the  distinction  of  being  termed 
test- teeth.  Hutchinson  attributes  some  of  the  other  defects  noticed 
upon  the  permanent  teeth  of  patients  with  inherited  syphilis  to  mer- 
cury, and  others  to  defects  in  the  enamel  due  to  a  variety  of  causes. 
Parrot, t  on  the  other  hand,  believes  that  little  rows  of  circular  depres- 
sions or  fissures  around  the  teeth,  especially  uj^on  the  canines  and  first 
molars,  making  the  crown  of  the  tooth  appear  as  if  divided  into  two 

*  "Illustrations  of  Clinical  Surgery,"  Fasc.  Ill,  Plate  XI,  Loudon,  18Y6. 
f  "Revue  Scicutifiquc,"  July  22,  1882,  p.  111. 


TREATMENT.  087 

parts  of  unequal  diaracter,  are  characteristic  of  inherited  syphilis.  In 
this  Hutchinson  docs  not  agree  with  him. 

Finally,  I  have  observed*  and  figured  a  most  characteristic  pair  of 
perfect  Ilutchinsonian  teeth  (notched  upper  incisors)  in  a  married 
woman  who  had  always  enjoyed  robust  health  until  she  acquired 
syphilis  from  her  husband.  She  came  to  me  with  a  typical  syphilitic 
roseola,  and  a  year  later  I  saw  her  again  with  a  pronounced  late  erup- 
tion, and  learned  that  the  course  of  her  symptoms  had  been  character- 
istic of  acquired  disease.  Therefore  in  this  case  either  the  test-tccth 
were  not  due  to  inherited  disease,  or,  if  they  were,  the  patient  had 
shown  herself  fully  capable  of  acquiring  the  malady  over  again  in  the 
ordinary  way,  and  her  acquired  malady  ran  a  course  in  no  way  modi- 
fied by  her  presumed  inherited  diathesis. 

Treatment  of  Inherited  Syphilis. — Before  a  child  is  born,  if  there 
is  reason  to  believe  that  it  is  syphilitic,  its  treatment  should  be  com- 
menced by  bringing  the  mother  mildly  under  the  influence  of  mer- 
cury. In  this  way  abortion  may  be  averted  and  the  child's  life  saved. 
A  positive  effect  of  mercury  should  be  aimed  at,  without,  if  possible, 
producing  any  diarrhoea  or  intestinal  irritation,  which  are  recognized 
by  most  observers  to  be  in  themselves  efficient  causes  of  abortion. 
Inunction  is  an  efficient  method,  but  it  is  not  at  all  essential.  I  have 
come  to  prefer  of  late  years  the  continued  use  of  a  combination  of  blue- 
pill  and  dried  sulphate  of  iron  in  these  cases. 

The  favorite  methods  of  treating  a  child  with  inherited  disease  are 
by  inunction  or  by  gray  powder.  The  former  is  dirty,  but  easy  to 
apply  upon  an  infant  by  the  method  which  bears  Brodie's  name — 
namely,  spreading  mercurial  ointment  upon  the  child's  belly-band. 
In  the  same  way  medicated  bandages  maybe  shifted  about  (to  prevent 
mercurial  eczema)  upon  the  child's  anus  and  legs.  Considerable 
washing  and  watching  are  sometimes  necessary,  when  this  method  is 
used,  to  prevent  the  local  irritation  of  the  skin.  Gray  powder  is  used 
in  doses  of  a  grain,  more  or  less,  repeated  according  to  symptoms  and 
the  effect  of  the  drug.  The  vomiting  of  the  child  is  rather  an  objec- 
tion to  the  use  of  this  powder,  which  is  otherwise  suitable. 

In  a  somewhat  limited  experience  in  the  management  of  infantile 
acquired  syphilis,  I  have  come  of  late  to  rely  mainly  upon  a  weak 
solution  of  the  bichloride  of  mercury  in  water,  provided  the  child  is 
supplied  with  an  intelligent  and  careful  nurse  or  mother.  A  half- 
grain  in  six  ounces  of  water  gives  a  ninety-sixth  part  of  a  grain  in 
each  drachm,  and  this  a  child  a  few  days  old  may  take  hourly  day  and 
night  if  need  be,  mixed  with  ordinary  food.  It  does  not  cause  vomit- 
ing or  diarrhoea,  and  the  dose  may  be  easily  raised  or  lowered  accord- 
ing to  its  effect.     It  is  well  borne  in  summer  or  winter,  and  in  some 

*  "  Cases  bearing  upon  Certain  Mooted  Points  in  Syphilology,"  "  New  York  Med. 
Journ.,"  April  25,  1885,  p.  466. 


688  INHERITED   SYnilLIS. 

cases  is  very  efTeetive.  It  may  be  used  to  commence  treatment  with, 
and  then,  if  the  child  rallies,  otlier  treatment,  inunction,  may  he  re- 
sorted to  later.  The  iodides  are  not  very  suitable  to  the  treatment  of 
the  earlier  stages  of  inherited  disease,  as  they  are  often  not  well  borne 
in  efficient  doses  by  the  baby  stomach.  For  the  tardy  lesions  as  the 
child  grows,  they  can  not  be  dispensed  with,  and  may  be  well  used 
tentatively  even  upon  the  young  infant.  If  the  mother  takes  the 
iodides  freely,  her  milk  contains  the  salt,  and  is  capable  of  producing 
iodic  acne  upon  the  nursing  child. 

Locally  the  excoriations  and  ulcers  require  cleanliness,  and  dusting 
with  zinc  oxide,  calomel,  even  iodoform,  or  the  use  of  mild  mercurial 
ointments.  The  nourishment  of  the  child  requires  the  closest  atten- 
tion, but  in  no  instance  should  a  syphilitic  infant  be  given  to  a  healthy 
wet-nurse.  If  this  is  done,  the  nurse  almost  inevitably  acquires  chan- 
cre at  the  nipple  from  a  mucous  j)atch  upon  the  lips  of  the  child,  and 
the  disease  may  be  thus  spread  indefinitely. 


GE^EEAL    IISTDEX. 


Ablation  of  the  scrotum,  455. 
Abortion  due  to  syphilis,  6*79. 
Abscess  corapUcating  stricture,  161. 

perinephritic,  336. 

prostatic,  209. 

prognosis  in,  210. 

treatment  of,  210. 
Acne,  iodic,  5'79. 

syphilitic,  general,  58*7. 
diagnosis  of,  588. 
Adenitis,  simple,  85,  485. 

syphilitic,  523,  548,  645. 

virulent,  487. 
Adults,  incontinence  of  urine  in,  233. 
Albuminuria,  iodic,  580. 
Alopecia  due  to  syphilis,  548 

treatment  of,  548. 
Amputation  of  the  penis,  9. 

partial,  10. 
Anaemia,  iodic,  580. 
Anatomy  of  the  prostate,  169. 
Anus,  syphilis  of  the,  657. 
Aphasia,  syphilitic,  674. 
Aponeuroses,  syphiHs  of  the,  637. 
Aquo-capsulitis,  gonorrheal,  91. 
Arteritis,  syphilitic,  648. 

of  the  brain,  666. 
Arthropathy,  syphilitic,  638. 
Aspermatism,  447. 

treatment  of,  448. 
Aspirator,  127. 
Atony  of  the  bladder,  226,  252. 

symptoms  of,  253. 

treatment  of,  254. 
Atrophy  of  the  prostate,  171. 

of  the  testicle,  368. 

treatment  of,  369. 
Azoospermatism,  448. 
44 


Bacilli  in  tubercular  prostatitis,  213. 
Balanitis,  21. 
causes  of,  21. 
diagnosis  of,  22. 
symptoms  of,  21. 
treatment  of,  22. 
Benique  instrument,  34. 
Bigelow's  lithotrite,  292. 
Bigelow's  washing-bottle,  292. 
Bladder,  anatomy  of  the,  218. 

anomalies  and  deformities  of  the,  220. 
atony  of  the,  226,  252. 

symptoms  of,  253. 

treatment  of,  254. 
atrophy  of  the,  226. 
bar  at  the  neck  of  the,  175. 
cancer  of  the,  259. 

symptoms  of,  260. 

treatment  of,  260. 
chorea  of  the,  233. 

treatment  of,  234. 
chronic  catarrh  of  the,  248. 

causes  of,  249. 

cystotomy  for,  252. 

symptoms  of,  251. 

treatment  of,  251. 
cysts  of  the,  259. 
exstrophy  of  the,  221. 

treatment  of,  222. 
fibrous  tumors  of  the,  259. 

symptoms  of,  259. 

treatment  of,  259. 
foreign  bodies  in  the,  229. 

treatment  of,  230. 
hernia  of  the,  224. 

treatment  of,  225. 
hypertrophy  of  the,  225. 
inflammation  of  the,  136,  243. 


690 


GENERAL   INDEX. 


Bladder,  injection  of  the,  197. 
neuralgia  of  the  neck  of  the,  237. 

causes  of,  238. 

diagnosis  of,  242. 

symptoms  of,  289. 

treatment  of,  242. 
papilloma  of  the  (villous  growth),  262. 

symptoms  of,  262. 

treatment  of,  203. 
paralysis  of  the,  255. 

treatment  of,  250. 
perforating  ulcer  of  the,  228. 
permanent  outlet  in,  129. 
puncture  (suprapubic),  127. 

point  of  election  of,  128. 

through  perinanmi,  130. 

through  rectum,  127. 

through  symphysis  pubis,  130. 
rupture  of  the,  143,  227. 

symptoms  of,  227. 

treatment  of,  22S. 
sacculation  of  the,  179. 
stone  in  the,  263. 

causes  of,  265. 

electrolytic  treatment  of,  288. 

means  of  preventing,  286. 
suprapubic  excision  of  the,  261. 

palliative  treatment  of,  289. 

solvent  treatment  of,  289. 
tapping,  innocuousness  of,  129. 
tubercle  of  the,  258. 

diagnosis  of,  258. 

treatment  of,  258. 
tumors  of  the,  257. 
villous  growth  of  the,  262. 
washing  the  dilated,  196. 
wounds  of  the,  226. 

treatment  of,  220. 
Bone,  syphilitic,  dry  caries  of,  644. 

treatment  of,  645, 
gumma  of,  643. 
syphilis  of,  641. 

forms  of,  642. 

prognosis  in,  685. 

symptoms  of,  684. 
Bougie,  109. 
bulbous,  113. 
conical,  112. 
English  yellow,  113. 
filiform,  109. 
Harrison's,  192. 
olive-tipped,  112. 
whalebone,  110. 
method  of  using,  110. 


Brain,  syphilis  of  the,  672. 
Bubo,  abortive  treatment  of,  490. 
chancroidal,  485,  529. 
complications  of,  487. 
diagnosis  of,  489. 
treatment  of,  489. 
phagedenic,  488. 
simple,  480. 

symptoms  of,  486. 
syphilitic,  523. 

diagnosis  of,  529. 
submaxillary  and  axillary,  524. 
suppuration  of,  524. 
treatment  of,  525. 
virulent,  487. 
Buck's  fascia,  3. 
BulUe,  iodic,  580. 
Bursae,  syphilis  of  the,  638. 

Cachexia,  syphilitic  tertiary,  601. 

urinary,   145. 
Calcification  of  the  penis,  26. 

causes  of,  26. 

prognosis  of,  26. 

treatment  of,  26. 
Calculi,  phosphatic,  266. 
prostatic,  216. 
renal,  326. 
vesical,  203. 

behavior  of  the  bladder  in,  271. 

choice  of  method  of  cure,  279. 

consequences  of,  269. 

desire  to  void  urine  in,  274. 

friability  of,  268. 

growth  of,  204. 

influence  of  the  age  of  patient  in  choice 
of  method  of  cure,  282. 

misplaced  sensations  in,  274. 

multiple,  268. 

pain  in,  273. 

pathological    conditions   of   the   urinary 
passages  in,  275. 

roughness  of,  269. 

size  of,  269. 

sounding  for,  277. 

symptoms  in,  271. 

volume  of,  267. 
Cancer  of  the  bladder,  259. 

sjTnptoms  of,  260. 

treatment  of,  200. 
Cancer  of  the  kidney,  347. 

diagnosis  of,  350. 

symptoms  of,  347. 

treatment  of,  350. 


GENERAL   INDEX. 


091 


Cancer  of  the  penia,  9. 

prognosis  in,  9. 
Cancer  of  the  prostate,  214. 

symptoms  of,  214. 

treatment  of,  215. 
Cancer  of  the  scrotum,  3G1. 
Cancer  of  the  testicle,  416. 

diagnosis  of,  41 Y. 

pathology  of,  417. 

prognosis  in,  418. 

symptoms  of,  416. 

treatment  of,  418. 
Caries,  dry  syphilitic,  644. 

treatment  of,  646. 
Castration,  422. 
Catalepsy,  syphilitic,  6*74. 
Catarrh  of  the  bladder,  chronic,  248. 

causes  of,  249. 

cystotomy  for,  252. 

symptoms  of,  251. 

treatment  of,  251. 
Catheter,  114. 

English  yellow  elastic,  114. 

Gross's,  190. 

method  of  securing  in  the  urethra,  189. 

Mercier's,  188. 

Nelaton's,  188. 

olivary,  114. 

self -use  of,  in  the  hypertrophy  of  the  pros- 
tate, 195. 

silver,  114. 
Catheter-fever,  194. 
Catheterism,  35. 

effects  of,  38. 

force  in,  37. 

method  of  performing,  35. 
Chancre,  Hunterian,  519. 

phagedenic,  521. 
Chancre,  syphilitic,  chancroid  in,  520. 

character  of  the  discharge  in,  502. 

cicatrix  of,  502. 

complications  of,  520. 

course  of,  504,  520. 

diagnosis  of,  526. 

duration  of,  517. 

erosion  of,  518. 

gangrenous,  521. 

in  chancroid,  473. 

induration  of,  500,  519. 

number  of,  517. 

pain  in,  502. 

prognosis  in,  522. 

size  of,  517. 

situation  of,  517. 


Cliancre,  treatment  of,  522. 

transformation  into  mucous  patch,  521. 
ulceration  of,  502,  519. 
urethral,  519. 
vegetations  in,  520. 
Chancroid,  460. 

auto-inoculability  of,  463. 
bubo  of,  529. 
cause  of,  461. 
complications  of,  472. 
condition  of  base  of,  471. 
contagiousness  of,  463. 

exceptions  to,  469. 
course  of,  468. 
diagnosis  of,  477. 
frequency  of,  464. 
gangrene  in,  473. 
general  treatment  of,  485. 
inflammation  in,  473. 
lymphangitis  of,  530. 
method  of  contagion  of,  465. 
non-inoculability  of,  in  fever,  462. 
paraphimosis  in,  483. 
period  of  incubation  of,  468. 
prognosis  in,  479. 
prophylactic  treatment  of,  479. 
relapse  in,  472. 
scar  of,  465. 
situation  of,  466. 
symptoms  of,  467. 
transmissibility  of,  to  animals,  461. 
treatment  of,  480. 
varieties  in  duration  of,  470. 

in  form  of,  469. 

in  number  of,  470. 

in  pain  of,  471. 

in  size  of,  470. 

in  shape  of,  470. 
vegetations  in,  472. 
anal,  483. 

in  syphilitic  chancre,  520. 
phagedenic,  474. 

local  treatment  of,  483. 
subpreputial,  482. 
syphilitic  chancre  in,  473. 
Chemosis,  97. 
Children,  lateral  lithotomy  in,  307. 

nocturnal  incontinence  of  urine  in,  232. 

treatment  of,  232. 
visceral  syphilis  in,  685. 
Chill,  urethral,  48. 
Chordee,  63. 

treatment  of,  72. 
Chorea  of  the  bladder,  233. 


692 


GENERAL   INDEX. 


Chorea  of  the  bladder,  treatment  of,  '234. 

sypliilitie,  674. 
Choroiditis,  syphilitic,  1)25. 

treatment  of,  C2(5. 
Ciliary  body,  ^vphilis  of  the,  023. 
Circumei.-^ion,  12. 

in  the  infant,  13. 

method  of  performing,  12. 

sutures  used  after,  13. 
Civiale's  urethrotome,  120. 
Cocaine,  hydrochlorate  of,  in  gonorrha}a,  09. 

in  urethrotomy,  122. 
Colic,  renal,  danger  in,  829. 

diagnosis  of,  330. 

symptoms  of,  828. 

treatment  of,-  331. 
Concretions,  prostatic,  216. 

substance  of,  216. 

treatment  of,  217. 
Congestion  of  the  prostate,  205. 
Conjunctiva,  syphilis  of  the,  611. 

treatment  of,  612. 
Conjunctivitis,  gonorrhoeal,  93. 

diagnosis  of,  94. 

prognosis  in,  95. 

symptoms  of,  93. 

treatment  of,  95. 
Contusion  of  the  penis,  5. 

treatment  of,  6. 
Contusion  of  the  testicle,  309. 

treatment  of,  309. 
Contusion  of  the  urethra,  45. 

treatment  of,  46. 
Copaiba,  68,  72,  73. 
Cord,  spermatic,  anatomy  of  the,  449. 

diseases  of  the,  450. 

hiematocele  of  the,  373. 

treatment  of,  373. 
Cornea,  syphilis  of  the,  613. 

course  of,  614. 

duration  of,  614. 

treatment  of,  614. 
Corpora  caveniosa,  1. 

inflammation  of  the,  25. 

treatment  of,  25. 

inflammation    of    the,    chronic    circum- 
scribed, 26. 
invasion  of,  26. 
prognosis  in,  29. 
Corpus  spongiosum,  urethral,  2. 

fracture  of  the,  7. 

function  of,  2. 
Countenance,  syphilitic,  in  inherited  disease, 
685. 


Cowperitis,  82. 
symptoms  of,  83. 
treatment  of,  83. 
Cowper's  glands,  32. 
Crcmaster  muscle,  spasm  of  the,  449. 
Cryptorchidism,  305. 
Crystalline  lens,  syphilis  of  the,  023. 
Cubebs,  73. 

oleo-rcsin  of,  74. 
Cyclitis,  syphilitic,  624. 
Cyst,  dermoid,  of  the  testicle,  423. 

of  the  bladder,  259. 
Cystitis,  acute,  245. 
sj'mptoms  of,  245. 
traumatic  causes  of,  245. 
ponorrhcval,  246. 

pathological  changes  in,  247. 
symptoms  of,  246. 
treatment  of,  247. 
in  hypertrophy  of  the  prostate,  200. 
interstitial,  244. 
Cystocele,  224. 

Dactylitis,  syphilitic,  634. 

diagnosis  of,  636. 

forms  of,  634. 

treatment  of,  636. 
Deformities  of  the  prostate,  170. 

of  the  urethra,  3v). 
Diarrhoea  in  general  syphilis,  562. 
Dieffenbach's  lace  suture,  105. 
Dilator,  Thompson's  rapid,  118. 
Dislocation  of  the  testicle,  368. 
Divulsion  of  stricture,  118. 
Dropsy  of  the  testicle,  374. 

cause  of,  375. 

Ear,  syphilis  of  the,  631. 

Eczema  niiuginatum  of  the  scrotum,  357. 

treatment  of,  358. 
Ecraseur,  the,  in  amputation  of  the  penis,  1 0. 
Ecthyma  in  tertiary  syphilis,  602. 
treatment  of,  602. 

superficial,  588. 
diagnosis  of,  588. 
Elephantiasis  scroti,  301. 
Era])hysema  of  the  scrotum,  357. 
Encephalitis,  sypliilitic,  665. 
Enchondroma  of  the  testicle,  418. 
Endoscope,  80. 
Epicystitis,  243. 
Epididymis,  364. 
Epididymitis,  144,  147,  393. 

causes  of,  395. 


GENERAL  INDEX, 


693 


Epididytnitis,    constitutional   symptomH   in, 
3'J8. 
date  of  its  appearance  in  gonorrhoea,  393. 
diagnosis  of,  400. 
frequency  of,  393. 
sterility  from,  399. 

treatment  of,  401. 
complicating  prostatic  abscess,  210. 
pseudo-tubercular,  406. 

treatment  of,  407. 
syphilitic,  411. 
Epilepsy,  syphilitic,  6*73. 
symptoms  of,  673. 
treatment  of,  674. 
Epispadias,  42. 

treatment  of,  43. 
Epithelioma  of  the  scrotum,  361. 
treatment  of,  362. 
penis,  24. 
diagnosis  of,  25. 
prognosis  in,  25, 
symptoms  of,  24. 
treatment  of,  25. 
Erotomania,  445. 

Erysipelas,  phlegmonous,  of    the   scrotum, 
359. 
diagnosis  of,  360. 
symptoms  of,  359. 
treatment  of,  360. 
Erythema,  copaibal,  72. 
iodic,  579. 
in  secondary  syphilis,  595. 
diagnosis  of,  595. 
treatment  of,  596. 
Exostosis,  epiphysary,  syphilitic,  643, 

diagnosis  of,  643. 
Exploration  of  the  urethra,  35. 
Extravasation  of  urine,  144. 
Exstrophy  of  the  bladder,  221. 

treatment  of,  222. 
Eye,  syphilis  of  the,  609. 
Eyelids,  syphilis  of  the,  610. 
mucous  patches  in,  611. 
primary  chancre  in,  610. 
ptosis  in,  611. 

False  passage  in  the  urethra,  155. 
Fascia,  Buck's,  3. 

Fever,  non-inoculability  of  chancroid  in,  462. 
syphilitic,  545. 

blood-corpuscles  in,  545. 

character  of,  546. 

diagnosis  of,  547, 

treatment  of,  547, 


Fcvor,  urethral  or  urinary,  48. 
treatment  of,  50. 
types  of,  48. 
Fistula  complicating  stricture,  161. 
urinary,  138, 

with  loss  of  substance,  164. 
Folliculitis,  82. 

Foreign  bodies  in  the  bladder,  229. 
treatment  of,  230. 
in  the  urethra,  52. 
treatment  of,  52. 
Fracture  of  the  penis,  treatment  of,  7. 
Fungus,  syphilitic,  of  the  testicle,  413. 
treatment  of,  415. 

Galvano-cautery  in  amputation  of  the  penis, 

10. 
Gangrene  in  chancroid,  473. 

in  syphilitic  chancre,  521. 
Glands,  Cowper's,  32. 

of  Tyson,  2. 
Glans  penis,  2. 

diseases  of  the,  20, 
Gleet,  63,  75. 

duration  of,  64. 

injections  in,  77. 

stricture  of  the  urethra,  134. 

significance  of,  64. 

the  endoscope  in,  80. 

treatment  of,  64,  76. 
Gonococcus  of  gonorrhoea,  56. 
Gonorrhosa,  54,  61. 

bastard,  61. 

complications  of,  64,  82. 

course  of,  63. 

date  of  the   appearance  of  epididymitis 
in,  393. 

decreasing  stage  of,  72. 

diagnostic  value  of  the  gonococcus  of,  58. 

duration  of,  63. 

effect  of  copaiba  in,  72. 

gonococcus  of,  56. 

hydrochlorate  of  cocaine  in,  69. 

hygiene  of,  67. 

increasing  stage  of,  68. 

injections  in,  74. 

Ricord's  receipt  for  getting,  60. 

sequelae  of,  81. 

stationary  stage  of,  71. 

symptoms  of,  61. 

time  of  occurrence  of  stricture  after,  107. 

wrappings  of  the  penis  in,  69. 
Gouley's  catheter-staff,  123. 
Gout,  influence  of,  on  general  syphilis,  539. 


C94 


GENEILIL  INDEX. 


Gravel,  ?.-26. 

symptoms  of,  S'26. 
treatment  of,  32G. 
Gross's  catheter,  190. 
Gumma  in  tertiary  syphilis,  606. 

treatment  of,  G07. 
of  bone,  643. 
of  the  larynx,  652. 
of  the  liver,  660. 
of  the  lungs,  652. 
of  muscle  in  syphilitic  myositis,  639. 

symptoms  of,  639. 

treatment  of,  640. 
of  the  brain-substance,  666. 
of  the  meninges,  665. 
of  the  spleen,  658. 
of  the  tongue,  054. 

diagnosis  of,  655. 

treatment  of,  656. 
"Gynomania,"  445. 

Harrison's  bougie,  192. 
Htematocele,  370. 

diagnosis  of,  371. 
treatment  of,  372. 
of  the  cord,  373. 
treatment  of,  373. 
Hsematuria,  234. 
causes  of,  236. 
treatment  of,  237. 
in  papilloma,  262. 
Hcemorrhage  after  urethrotomy,  120. 
in  litholapaxy,  295. 
in  the  deep  urethra,  control  of,  121. 
Hemiplegia,  syphilitic,  672. 
Hepatitis,  syphilitic  interstitial,  659. 
symptoms  of,  661. 
treatment  of,  662. 
Herpes  progenitalis,  20. 
diagnosis  of,  21. 
treatment  of,  21. 
syphilitic,  526. 
Hernia  complicating  diseased  testicle,  423. 
of  the  bladder,  224. 
treatment  of,  225. 
Horns,  cutaneous,  of  the  penis,  9. 
Hutchinson's  teeth,  6S6. 
Hydrarthrosis,  88. 

secondary,  88. 
Hydrocele,  acupuncture  in,  379. 
acute,  375. 
chronic,  376. 
diagnosis  of,  377. 
differential  diagnosis  of,  376. 


Hydrocele,  encysted,  of  the  spermatic  cord, 
388. 

treatment  of,  388. 
encysted,  of  the  testicle,  884. 

incision  in,  382. 

injection  in,  880. 

radical  treatment  of,  379. 

symptoms  of,  376. 

tapping  of,  378. 

treatment  of,  378. 
congenital,  382. 

diagnosis  of,  382. 

treatment  of,  383. 
of  hernial  sac,  383. 

diagnosis  of,  383. 

treatment  of,  383. 
spurious,  384. 

treatment  of,  384. 
of  the  spermatic  cord,  387. 

diagnosis  of,  387. 

symptoms  of,  387." 

treatment  of,  387. 
Hydronephrosis,  339. 
causes  of,  340. 
course  of,  341. 
diagnosis  of,  341. 
symptoms  of,  341. 
treatment  of,  342. 
Hygiene,  urethral  and  sexual,  43. 
Hypertrophy  of  the  bladder,  225. 
of  the  prostate,  172. 

centric  median,  175. 

course  of  symptoms  of,  182. 

cystitis  in,  200. 

diagnosis  of,  184. 

internal  remedies  in,  201. 

methods  of  estimating,  190. 

mode  of  death  in,  204. 

radical  treatment  of,  by  medicine,  203. 

retention  of  urine  in,  178. 

self -use  of  the  catheter  in,  195. 

surgical  measures  in,  203. 

Thompson's  method  of  diagnosticating, 
187. 

test  for  residual  urine  in,  193. 

treatment  of,  192. 

treatment  of  complications  in,  199. 
of  the  testicle,  368. 
Hypodermic  injection  of  mercury,  564. 
Hypospadias,  40. 
complications  of,  42. 

Impotence,  false,  431. 
treatment  of,  433. 


GENERAL  INDEX. 


G05 


Impotence,  nervous,  433. 
treatment  of,  434. 
significance  of,  4'27. 
true,  conditions  involving,  428. 
Incontinence  of  urine,  232. 
in  adults,  2.^3. 
nocturnal,  in  cliildren,  232. 
treatment  of,  232. 
Infiltration  of  urine  complicating  stricture, 
159. 
direction  in,  142. 
in  stricture,  139. 
symptoms  in,  143. 
Inflammation  in  chancroid,  4*73. 
in  syphilitic  chancre,  520. 
lacunal,  82. 
of  the  bladder,  243. 

of  the   corpora   cavernosa,   chronic   cir- 
cumscribed, 26. 
invasion  of,  26. 
prognosis  in,  29. 
treatment  of,  29. 
of  the  kidney,  333. 
causes  of,  333. 
prognosis  in,  33*7. 
symptoms  of,  335. 
treatment  of,  338. 
of  the  testicle,  388. 
of  the  urethra,  causes  of,  55. 
treatment  of,  65. 
urethral  injections  in,  65. 
urethral  symptoms  of,  61. 
Injection  of  the  urethra,  65. 

of  the  deep  urethra,  7*7. 
Injuries  of  the  prostate,  lYl. 

of  the  urethra,  45. 
Insanity,  syphilitic,  674. 
Instruments,  curve  of  urethral,  34. 

for  internal  urethrotomy,  119. 
Intertrigo  of  the  scrotum,  357. 
Intestine,  syphilis  of  the,  656. 
Iodides,  acne  from,  579. 
albuminuria  from,  580. 
anaemia  with  nervous  prostration  from, 

580. 
bad  effects  of,  means  of  diminishing,  581. 
bullae  from,  580. 
cutaneous  eruptions  from,  579. 
effects  of,  on  mucous  membranes,  578. 
erythema  from,  579. 
iodoform  as  a  substitute  for,  581. 
purpura  from,  579. 
lodism,  578. 
Iodoform  as  a  substitute  for  the  iodides,  581. 


Irrigation  of  the  urethra,  66. 
Iris,  syphilis  of  the,  615. 

treatment  of,  616. 
Iritis,  gonorrhajal,  92. 
Iritis,  syphilitic,  616. 

complications  of,  617. 

prognosis  in,  618. 

symptoms  of,  616. 

treatment  of,  619. 

Jaundice,  syphilitic,  547. 
Joints,  syphilis  of  the,  640. 

diagnosis  of,  641. 

treatment  of,  641. 

Keratitis,  syphilitic,  interstitial,  613. 
Kidney,  ablation  of  the,  351. 
absence  of  the,  318. 
anatomy  of  the,  318. 
atrophy  of  the,  333. 
cancer  of  the,  347. 

diagnosis  of,  350. 

symptoms  of,  347. 

treatment  of,  350. 
colic,  danger  in,  329. 

diagnosis  of,  330. 

symptoms  of,  328. 

treatment  of,  331. 
contusions  and  wounds  of,  319. 
cysts  of  the,  343. 

prognosis  in,  344. 

symptoms  of,  344. 

treatment  of,  344. 
displacement  of  the,  318. 
floating,  318. 
horseshoe,  318. 
hydatids  of  the,  343. 
incision  of  the,  351. 
inflammation  of  the,  333. 

causes  of,  333. 

prognosis  in,  337. 

symptoms  of,  335. 

treatment  of,  338. 
laceration  of,  prognosis  in,  320. 

symptoms  of,  319. 

treatment  of,  320. 
multiple,  318. 
scrofulous,  345. 
stone  in  the,  326. 

formation  of,  326. 

removal  of,  332. 

symptoms  of,  327. 

treatment  of,  327. 
syphilis  of  the,  353,  663. 


696 


GENERAL   INDEX. 


Kidney,  syphilis  of  the,  pathology  of,  365. 
treatment  of,  055. 
tubercle  of  the,  845. 
tumors  of  the,  350. 

Lacuna  magna,  32. 
Lafayette  mixture,  C-9. 
Larynx,  syphilis  of  the,  650. 
Laryngitis,  syphilitic,  gummy  ulcerative,  651. 
diagnosis  of,  651. 
treatment  of,  651. 
non-ulcerative,  650. 
diagnosis  of,  651. 
"  Lesbian  love,"  445. 
Lipoma  of  the  testicle,  420. 
Lithic  acid,  insolubility  of,  264. 
Litholapaxy,  290. 

after-treatment  of,  296. 
cases  suitable  for,  290. 
complications  of,  296. 
haemorrhage  in,  295. 
instruments  required  for,  291. 
method  of  performing,  293. 
■  preparation  of  i)atient  for,  291 
relapse  after,  297. 
Lithotomy,  297. 

complications  of,  310. 
after-treatment  of,  306. 

opium  in,  307. 
ha?morrhage  in,  305. 

venous,  306. 
lateral,  298. 

instruments  for,  299. 
in  children,  307. 
manner  of  performing,  301. 
origin  of,  208. 
median,  308. 

instruments  for,  308. 
manner  of  performing,  308. 
suprapubic,  312. 

after-treatment,  315. 
instruments  required  for,  312. 
manner  of  performing,  313. 
treatment  of  the  wound  in,  314. 
Lithotrite,  Bigelow's,  292. 
Lithotrity,  282. 

objections  against,  283. 
preparatory  treatment  for,  284. 
Liver,  gumma  of  the,  660. 

syphilis  of  the,  659. 

Lungs,  syphilitic  gumma  of  the,  652. 

diagnosis  of,  653. 

symptoms  of,  6.t3. 

treatment  of,  653. 


Lungs,  syphilis  of  the,  652. 
Lymphadenoma  of  the  testicle,  418. 
Lymphangitis,  85,  4'.»1. 

chancroidal,  530. 

forms  of,  85. 

inllummatory,  8. 

syphilitic,  525,  530. 

treatment  of,  88,  492. 

Maisonneuve's  urethrotome,  120. 

objection  to,  121. 
Marriage,  syphilis  and,  537. 
Mastitis,  syjjhilitie  dilfuse,  647. 

gummy,  647. 
Masturbation,  435. 
symptoms  of,  438. 
treatment  of,  439. 
Meatus,  normal,  149. 
occlusion  of  the,  40. 
stricture  of  the,  154. 
Menzel  on  infiltration  of  urine,  140. 
Mercier's  catheter,  188. 
Mercury,  bichloride  of,  66. 
elimination  of,  562. 
in  general  syphilis,  556. 

bad  effects  of,  559. 
method  of  administering,  563. 
fumigation,  564. 
hypodermic,  5G4. 
inunction,  566. 
internal,  569. 
local,  567. 
tonic  method   of    treatment  of  general 
syphilis  by,  571. 
Monorchidism,  365. 
Muscles,  deep  urethral,  2. 

syphilis  of  the,  638. 
Mydriasis,  syphilitic,  615. 
Myositis,  syphilitic,  congestive,  638. 
difluse  interstitial,  639. 

treatment  of,  639. 
syphilitic,  gumma  of  muscle  in,  639. 
symptoms  of,  639. 
treatment  of,  640. 
Myocarditis,  syphilitic,  647. 
diagnosis  of,  648. 
symptoms  of,  648. 
treatment  of,  648. 
Myoma  of  the  testicle,  418. 
Myxoma  of  the  testicle,  418. 

Nails,  syphilis  of  the,  632. 
diagnosis  of,  633. 
treatment  of,  633. 


GENERAL  INDEX. 


697 


Neissen  on  gonorrhcea,  R6. 
Nelaton's  catheter,  188. 
Nephralgia,  321. 

causes  of,  322. 

condition  of  urine  in,  322. 

diagnosis  of,  323. 

prognosis  in,  323. 

treatment  of,  323. 
Nephrectomy,  351. 

abdominal,  353. 

lumbar,  352. 
Nephrolitliotomy,  331. 

after-treatment  of,  332. 

complications  of,  332. 
Nephrorraphy,  319. 
Nephrotomy,  351. 
Neuralgia  of  the  neck  of  the  bladder,  237. 

causes  of,  238. 

diagnosis  of,  242. 

symptoms  of,  239. 

treatment  of,  242. 
Neuralgia  of  the  testicle,  425. 

treatment  of,  426. 
Neuritis  optica,  syphilitic,  628. 

prognosis  in,  628. 

treatment  of,  628. 
Noyes  on  syphilis  of  the  eye,  601. 

ffidema  of  the  scrotum,  356. 
(Esophagus,  syphilis  of  the,  656. 
Ophthalmia,  gonorrhoeal,  91. 
gonorrhceal,  rheumatic,  91. 
course  of,  92. 
symptoms  of,  91. 
treatment  of,  92. 
Opium  in  the  after-treatment  of  lithotomy, 

307. 
Orbital  nerves,  syphilis  of  the,  629. 
periosteal  inflammation  in,  630. 
treatment  of,  630. 
Orchitis,  369. 
causes  of,  389. 
pathological  changes  in,  391. 
prognosis  in,  392. 
symptoms  of,  390. 
terminations  of,  391. 
treatment  of,  392. 
syphilitic,  411. 

differential  diagnosis  of,  420. 
diffuse  form  of,  412. 
gummy  form  of,  412. 
prognosis  in,  414. 
symptoms  of,  413. 
treatment  of,  415. 


Ossification  of  the  penis,  25. 
Ostcocliondritis,  syphilitic,  682. 
Osteoperiostitis,  syphilitic,  642. 
Osteophytes,  syphilitic,  683. 
Otis's  dilating  urethrotome,  122. 

stylet,  189. 

urethramcter,  113. 
Oxaluria,  treatment  of,  325. 

Paederasty,  445. 

Pachymeningitis,  syphilitic,  664. 
Pancreas,  syphilis  of  the,  658. 
Papillae,  the  minute,  2. 
Papilloma  of  the  bladder  (villous  growth), 
262. 
symptoms  of,  262. 
treatment  of,  263. 
Paralysis  of  the  bladder,  255. 
treatment  of,  256. 
reflex  urinary,  137. 
syphilitic,  674. 
Paraplegia,  syphilitic,  675. 

treatment  of,  676. 
Paraphimosis,  17. 
causes  of,  17. 
inflammatory,  17. 
symptoms  of,  17. 
treatment  of,  18. 
with  strangulation,  18. 

method  of  reducing,  18. 
without  strangulation,  19. 
method  of  reducing,  19. 
Passage,  false,  155. 
Pediculi  pubis,  359. 
Pemphigus,  syphilitic,  infantile,  681. 
Penis,  1. 

absence  of  the,  5. 
accidents  to  the,  5. 
amputation  of  the,  9. 
galvano-cautery  in,  10. 
the  ecrasenr  in,  10. 
amputation,  partial,  of  the,  10. 
anomalies  of  the,  4. 
calcification  of  the,  26. 
causes  of,  26. 
prognosis  in,  26. 
treatment  of,  26. 
cancer  of  the,  9. 

prognosis  in,  9. 
contusions  of  the,  5. 

treatment  of,  6. 
cutaneous  affections  of  the,  8. 
cutaneous  horns  of  the,  9. 
dislocation  of  the,  7. 


698 


GENERAL   INDEX. 


Tcnis,  double,  4. 
fracture  of  tbc,  6. 
treatnicnt  of,  7. 
lymphatic  affections  of  the,  8. 
ossification  of  the,  25. 
partial  development  of  the,  5. 
skin  of  the,  3. 
tiunors  of  the,  9. 
wounds  of  the,  G. 
treatment  of,  6. 
wrappings  of,  in  gonorrhea,  69. 
Tericarditis,  syphilitic,  647. 
Pericystitis,  243. 

eomplicating  stricture,  102. 
Peritonitis,  syphilitic,  602. 
Peri-urcthritis,  83. 
treatment  of,  84. 
Phagedena,  general,  476. 
local,  476. 

treatment  of,  483. 
in  chancroid,  474. 
in  syphilitic  chancre,  521. 
Phimosis,  12,  1.3. 
inflammatory,  16. 

treatment  of,  16. 
operations  for,  14. 
remote  results  of,  17. 
Pityriasis  of  the  scrotum,  357. 
Pneumaturia,  257. 
Pneumonia,  syphilitic,  chronic,  052. 
Pollution,  diurnal,  442. 
nocturnal,  440. 
treatment  of,  441. 
Polymorphism,  541. 
Polypi  in  the  urethra,  53. 
Posthitis,  21. 
Prepuce,  the,  4,11. 
deformities  of  the,  11. 
length  of  the,  11. 
morbid  conditions  of  the,  15. 
Prostate,  169. 

abscess  of  the,  209. 
analogy  of  the,  to  the  uterus,  192. 
anatomy  of  the,  169. 
atrophy  of  the,  171. 
cancer  of  the,  214. 
symptoms  of,  214. 
treatment  of,  215. 
congestion  of  the,  205. 
deformities  of  the,  170. 
enlarged,  eomplicating  stricture,  163. 
function  of  the,  170. 
hypertrophy  of  the,  172. 
cause  of,  172. 


1  Prostate,   hypertrophy    of    the,   course  of 
'  symptoms  of,  182. 

cystitis  in,  200. 
diagnosis  of,  184. 
internal  remedies  in,  201, 
methods  of  estimating,  190. 
mode  of  death  in,  2o4. 
radical  treatment  of,  by  medicine,  203. 
retention  of  urine  in,  1 78. 
self-use  of  the  catheter  in,  195. 
surgical  measures  in,  203. 
symptoms  and  result  of,  175. 
test  for  residual  urine  in,  193. 
Thompson's  method  of  diagnosticating, 

187. 
treatment  of,  192. 
treatment  of  complications  in,  199. 
injuries  of  the,  171. 
shape  of  the,  173. 
size  of  the,  170,  173. 
syphilis  of  the,  218. 
Prostatitis,  follicular,  211. 
symptoms  of,  211. 
treatment  of,  212. 
gonorrhoeal,  208. 
parenchymatous,  causes  of,  206. 
course  of,  206. 
symptoms  of,  206. 
treatment  of,  208. 
tubercular,  bacilli  in,  213. 
course  of,  213. 
prognosis  in,  214. 
symptoms  of,  213. 
treatment  of,  214. 
Prostatorrhoea,  211. 
Priapism,  446. 

treatment  of,  447. 
Pruritus  genitalium,  358. 
Purpura,  iodic,  579. 
Pyelitis,  333. 
causes  of,  333. 
prognosis  in,  337.     - 
symptoms  of,  335. 
treatment  of,  338. 
Pyelonephritis,  tubercular,  345. 
diagnosis  of,  346. 
symptoms  of,  346. 
treatment  of,  346. 
Pyonephrosis,  333. 


Rectum,  syphilis  of  the,  657. 
Retention  of  urine,  231. 

complicating  stricture,  157. 

in  impassable  stricture,  158. 


GENERAL   INDEX. 


699 


Retention  of  urine,  treatment  of,  2'n. 
Retinitis,  syphilitic,  627. 

treatment  of,  O'iY. 
Rlicumatism,  gonorrlioeal,  86. 

appearance  of,  87. 

distinguished  from  simple,  90. 

immunity  of  women  from,  87. 

oil  of  wintergreen  in,  91. 

the  seat  of,  87. 

treatment  of,  90. 

varieties  of,  88,  89. 
Ricord  on  gonorrhoea,  66,  59. 
Ricord's  receipt  for  getting  gonorrhoea,  60. 
Roseola,  syphilitic,  584. 

diagnosis  of,  585. 

time  of  appearance  of,  585. 
Rapia  in  tertiary  syphilis,  602. 

treatment  of,  603. 
Rupture  of  the  bLadder,  143,  227. 

symptoms  of,  227. 

treatment  of,  228. 

Sacculation  of  the  bladder,  179. 
Salivation  in  general  syphilis,  560. 
cause  of,  561. 
symptoms  of,  561. 
treatment  of,  561. 

in  late  syphilis,  578, 
Sandal- wood  oil,  68,  71,  74. 
Sarcoma  of  the  testicle,  418. 

differential  diagnosis  of,  420. 

pathology  of,  419. 

symptoms  of,  418. 

treatment  of,  420. 
Satyriasis,  446. 

Scale  for  measuring  sounds,  116. 
Sclera,  syphilis  of  the,  612. 

treatment  of,  613. 
Sclerosis  of  the  tongue,  654. 
Scrofula,  influence  of,  in  general  syphilis, 

539. 
Scrotum,  ablation  of  the,  455. 

anatomy  of  the,  355. 

cancer  of  the,  361. 

cutaneous  affections  of  the,  856. 

eczema  marginatum  of  the,  357. 
treatment  of,  358. 

elephantiasis  of  the,  361. 

emphysema  of  the,  357. 

eijithelioma  of  the,  361. 
treatment  of,  362. 

injuries  of  the,  356. 

intertrigo  of  the,  857. 

lymph,  361. 


Sciotum,  crdema  of  the,  356. 

phlegmonous  erysipelas  of  the,  359. 
diagnosis  of,  'iCiO. 
symptoms  of,  359. 
treatment  of,  360. 
pityriasis  of  the,  357. 
Self-abuse,  435. 
Sinuses  of  Morgagni,  32. 
Sounds,  conical,  115. 
steel,  115. 

advantages  of,   for   dilating   stricture, 
117. 
Sperm,  blue,  445. 
Spermatocele,  384. 
symptoms  of,  386. 
treatment  of,  386. 
Spermatorrhoea,  442. 
causes  of,  448. 
treatment  of,  444. 
Spleen,  syphilis  of  the,  658. 
Sterility,  434. 

Stomach,  syphilis  of  the,  656. 
Stone,  case  of  instruments  for,  311. 
Stone  in  the  bladder,  263. 
causes  of,  265. 

electrolytic  treatment  of,  288. 
means  of  preventing,  286. 
palliative  treatment  of,  289. 
solvent  treatment  of,  289. 
in  the  kidney,  326. 
prostatic,  216. 
Stricture,  advantages  of  steel  instruments 
for  dilating,  117. 
division  of,  119. 
of  the  meatus,  154. 
of  the  urethra,  98. 
annular,  102. 
cause  of,  105. 
causes  of  death  in,  144. 
complicated,  155. 
complicated  by  abscess,  161. 
by  enlarged  prostate,  163. 
by  epididymitis,  144. 
by  fistulce,  161. 
by  pericystitis,  162. 
constitutional  disturbance  in,  144. 
continuous  dilatation  in,  163. 
diagnosis  of,  130. 
divulsiou  of,  118,  152. 
effects  of  force  in,  147. 
effect  of  the  sexual  element  in,  145. 
extravasation  of  urine  in,  138. 
gleet  of,  134. 
infiltration  of  urine  in,  139. 


roo 


GENERAL   INDEX. 


Stricture  of  the  urctlira,  internal  urethrot- 
omy in,  152. 

intervals  between  sittings  in,  148. 

irritable,  108. 

lesion  in,  104. 

linear,  102. 

loealization  of,  131. 

number  of,  103. 

objections   to    certain   operations   on, 
127. 

of  small  caliber,  treatment  of,  153. 

organic,  102. 

resilient,  108,  155. 

seat  of,  103. 

size  of  instrument  used  in,  117. 

spasmodic,  99. 
cause  of,  99. 
diagnosis  of,  101. 

summary  of  treatment  of,  1G7. 

symptoms  and  results,  132. 

time   of  the   occurrence   after   gonor- 
rhoea aud  injury,  107. 

tortuous,  102. 

treatment  of  uncomplicated,  14G. 

treatment  of  spasmodic,  101. 

traumatic,  154. 
Suppression  of  urine,  320. 
diagnosis  of,  321. 
symptoms  of,  220. 
treatment  of,  321. 
Sutures  used  after  circumcision,  13. 
Syphilide,  532. 
bullous,  589. 

characteristics  of  ulcers,  543. 
cicatrices  of,  543. 
color  of,  541. 

early  and  late  eruptions,  542. 
general  characteristics  of,  540. 
pain  and  itching  in,  542. 
papular,  585. 

diagnosis  of,  58G. 
pigmentary,  589. 

diagnosis  of,  589. 
pustular,  general,  587. 

superficial,  587. 
pustular  in   groups  in   tertiary  syphilis, 
603. 

diagnosis  of,  603. 

treatment  of,  604. 
rounded  form  of,  541. 
scabs  of,  543. 
scales  of,  543. 
secondary,  584. 
squamous,  591. 


Syphilide,  squamous,  generalized,  591. 
diagnosis  of,  591. 
squamous,  palmar  and  plantar,  592. 
diagnosis  of,  502. 
treatment  of,  5i»3. 
tertiary,  602. 
tubercular,  general,  593. 
diagnosis  of,  593. 
treatment  of,  594. 
tubercular  in  groups,  594. 
diagnosis  of,  595. 
treatment  of,  595. 
varicelloid,  590. 

diagnosis  of,  590. 
vesicular  in  groups,  590. 
diagnosis  of,  591. 
generiilized,  690. 
diagnosis  of,  590. 
Syphilis,  492. 

abortion  due  to,  679. 
absorption  of  virus  of,  495. 
and  marriage,  537. 
antagonism  with  cancer,  493. 
auto-inoculation  of,  503. 
general,  530. 

alopecia  due  to,  548. 
treatment  of,  548. 
analgesia  in,  549. 

causes  of  protracted  duration  of,  538. 
curability  of,  536. 
cutaneous  anajsthesia  in,  549. 
cutaneous  lesions  in,  567. 
diarrhoea  in,  562. 
duration  of,  535. 
early  treatment  of,  555. 
fever  in,  545. 

blood-corpuscles  in,  545. 
character  of,  546. 
diagnosis  of,  547. 
treatment  of,  547. 
glandular  engorgement  in,  548. 
Hot  Springs  of  Arkansas  in,  553. 
hygienic  treatment  of,  550. 
secondary  incubation  of,  544. 
influence  of  age  on,  534. 
of  excesses  on,  534. 
of  gout  and  scrofula  on,  539. 
of  idios}Ticrasy  on,  533. 
of  local  irritations  on,  534. 
of  phegadenic  chancre  on,  533. 
of  surroundings  on,  535. 
iritis  in,  550. 
manageablencss  of,  537. 
mucous  patches  in,  568. 


GENERAL   INDEX. 


701 


Sypliilis,  general,  mucous  patches  in,  local 
treatment  of,  509. 
prognosis  in,  532. 

salivation  in,  560. 
cause  of,  501. 
symptoms  of,  561. 
treatment  of,  561. 

specific  treatment  of,  551. 

sore  throat  in,  549. 

treatment  of,  mercurial,  556. 
bad  effects  of,  559.    ' 

treatment  of,  tonic  mercurial,  571. 

ulceration  of  the  skin  in,  568. 
incubation  of,  499. 
inherited,  510. 

countenance  in,  685. 

date  of  appearance  of,  6*79. 

prognosis  in,  685. 

symptoms  of,  685. 

teeth  in,  686. 

treatment  of,  687. 

in  the  second  generation,  614. 
inoculation  of,  503. 
inoculation  of,  multiple,  505. 
late,  duration  of  treatment  of,  581. 

iodides  in,  576. 
bad  effects  of,  577. 
dose  of,  577. 

salivation  in,  578. 

treatment  of,  575. 
mixed,  575. 
method  of  transmission  of,  509. 
methods  of  contagion  of,  515. 
of  the  anus,  657. 
of  the  aponeuroses,  637. 
of  the  arteries,  648. 
of  the  brain,  672. 
of  bones,  641. 

forms  of,  642. 

prognosis  in,  685. 

symptoms  of,  684. 
of  the  bursiB,  638. 
of  the  choroid,  625. 

treatment  of,  626. 
of  the  ciliary  body,  624, 
of  the  conjunctiva,  611. 

treatment  of,  612. 
of  the  cornea,  613. 

course  of,  614. 

duration  of,  614. 

treatment  of,  614. 
of  the  crystalline  lens,  623. 
of  the  ear,  631. 

external  ear,  631. 


Hypliilis  of  the  middle  ear,  631. 
of  the  eye,  609. 
of  the  eyelids,  610. 

mucous  patches  in,  610 

primary  chancre  in,  610. 

ptosis  in,  611. 
of  the  fingers,  634. 

diagnosis  of,  636. 

forms  of,  634. 

treatment  of,  636. 
of  the  heart,  647. 
of  the  intestine,  656. 
of  the  iris,  615. 

treatment  of,  616. 
of  the  joints,  640. 

diagnosis  of,  641. 

treatment  of,  641. 
of  the  kidney,  353,  663. 

pathology  of,  355. 

treatment  of,  355. 
of  the  lachrymal  apparatus,  610. 
of  the  larynx,  650. 
of  the  liver,  659. 
of  the  lungs,  652. 
of  the  lymphatic  glands,  645. 
of  the  mammary  glands,  646. 
of  the  muscles,  638. 
of  the  nails,  632. 

diagnosis  of,  633. 

treatment  of,  633. 
of  the  nervous  system,  663. 

causes  of,  664. 

genei'al  treatment  of,  671. 

prognosis  in,  670. 

symptoms  of,  667. 
of  the  oesophagus,  656. 
of  the  optic  nerve,  628. 

prognosis  of,  628. 

treatment  of,  628. 
of  the  oi'bital  nerves,  629. 

periosteal  inflammation  in,  630. 

treatment  of,  630. 
of  the  pancreas,  658. 
of  the  peritoneum,  662. 
of  the  prostate,  218. 
of  the  rectum,  657. 
of  the  retina,  627. 

treatment  of,  627. 
of  the  sclerotic  coat,  612. 

treatment  of,  613. 
of  skin  and  mucous  membranes,  584. 
of  special  nerves,  676. 

fifth  pair,  677. 

fourth  pair,  677. 


ro2 


GENERAL   INDEX. 


Syphilis  of  special  nerves,  seventh  pair,  678. 
sixth  pair,  C77. 
third  pair,  07fi. 
of  spinal  nerves,  678. 
of  the  spleen,  6u8. 
of  the  spinal  cord,  674. 
of  the  stomach,  656. 
of  the  tendons,  637. 
diagnosis  of,  637. 
tieatmeut  of,  638. 
of  the  toes,  634. 
diagnosis  of,  636. 
forms  of,  634. 
treatment  of,  636. 
of  the  tongue,  654. 
of  the  urethra,  662. 
of  the  vascular  system,  047. 
of  the  veins,  649. 
of  the  vitreous  humor,  G22. 
secondary,  531. 

concomitant  symptoms  of,  544. 
duration  of,  532. 
erythema  in,  595. 
diagnosis  of,  595. 
treatment  of,  596. 
mucous  patches  in,  597. 
diagnosis  of,  598. 
treatment  of,  599. 
scaly  patches  in,  599. 
diagnosis  of,  599. 
treatment  of,  600. 
ulcers  in,  596. 

symptoms  of,  597. 
treatment  of,  597. 
second  attacks  of,  496. 
secretions  capable  of  transmitting,  506. 
tertiary,  531,  600. 

aflections  of  mucous  membranes  in,  607. 
appearance  of  symptoms  of,  601. 
cachexia  in,  601. 
deep  ulcer  in,  605. 
diagnosis  of,  605. 
treatment  of,  606. 
destructive  gummy  ulceration  in,  608. 

treatment  of,  609. 
ecthyma  in,  602. 

treatment  of,  602. 
gumma  in,  606. 

treatment  of,  607. 
pustular  syphilide  in  groups  in,  603. 
diagnosis  of,  603. 
treatment  of,  604. 
rupia  in,  602. 

treatment  of,  603. 


Syphilis,  tertiary,  superficial  ulcer  in,  604. 
diagnosis  of,  605. 
treatment  of,  605. 
time  of  appearance  of,  532. 
transmi-ssibility  of,  493. 

to  animals,  49S. 
unity  and  duality  of,  494. 
visceral,  in  children,  685. 
Syphilization,  553. 

Tendons,  syphilis  of  the,  637. 
diagnosis  of,  637. 
treatment  of,  638. 
Tenesmus,  vesical,  233. 
Testicle,  absence  of  the,  305. 
anatomy  of  the,  362. 
anomalies  of  the,  365. 
atrophy  of  the,  368. 

treatment  of,  309. 
cancer  of  the,  416. 

diagnosis  of,  417. 

pathology  of,  417. 

prognosis  in,  418. 

symptoms  of,  416. 

treatment  of,  418. 
contusions  of  the,  369. 

treatment  of,  309. 
dermoid  cyst  of  the,  423. 
dislocation  of  the,  368. 
dropsy  of  the,  374. 

cause  of,  375. 
enchondroma  of  the,  418. 
encysted  hydrocele  of  the,  384. 
effusion  of  blood  into  the  sheath  of  the, 
370. 

diagnosis  of,  371. 

treatment  of,  372. 
hernia  complicating  disease  of  the,  423. 
hypertrophy  of  the,  368. 
inflammation  of  the,  388. 
irritable,  424. 

causes  of,  424. 

treatment  of,  425. 
lipoma  of  the,  420. 
lynipliadenoma  of  the,  418. 
myxoma  of  the,  418. 
neuralgia  of  the,  425. 

treatment  of,  426. 
operation  to  replace  a,  30*7. 
removal  of  the,  422. 
sarcoma  of  the,  418. 

diagnosis  of,  420. 

prognosis  in,  419. 

symptoms  of,  418. 


GENERAL   INDEX. 


703 


Testicle,  sarcoma  of  the,  treatment  of,  420. 
size  and  weight  of  the,  363. 
strapping  the,  contrivances  for,  405. 

in  epididymitis,  403. 
syphiUs  of  the,  410. 

forms  of,  411. 
syphilitic  fungus  of  the,  413. 
differential  diagnosis  of,  420. 
treatment  of,  415. 
tubercle  of  the,  40Y. 

differential  diagnosis  of;  420. 
pathology  of,  409. 
symptoms  of,  408. 
treatment  of,  409. 
undescended,  365. 
undeveloped,  366. 
wounds  of  the,  369. 
treatment  of,  370. 
Thompson's  method  of  diagnosticating  hy- 
pei'trophy  of  the  prostate,  187. 
rapid  dilator,  118. 
stone-searcher,  191. 
Thymus,  syphilis  of  the,  662. 
Tongue,  gumma  of  the,  654. 
diagnosis  of,  655. 
treatment  of,  656. 
sclerosis  of  the,  654. 
syphihs  of  the,  654. 
Tour  de  m^itre,  38. 
Tribadism,  445. 
Tubercle  of  the  bladder,  258, 
diagnosis  of,  258. 
treatment  of,  258. 
Tumor  of  the  bladder,  257. 
fibrous,  259. 

symptoms  of,  259. 
treatment  of,  259. 
of  the  kidney,  350. 
of  the  penis,  9. 
Tunica  albuginea,  1. 

vaginalis,  excrescences  in  the,  373. 

Ulcer  in  secondary  syphilis,  596. 
symptoms  of,  597. 
treatment  of,  597. 

perforating,  of  the  bladder,  228. 
Urachus,  patent,  225. 
Uraemia,  144. 
Ureter,  anatomy  of  the,  316. 

anomalies  of  the,  316. 

dilatation  of  the,  316. 

inflammation  of  the,  316. 

stricture  of  the,  317. 

wounds  of  the,  316. 


Urethra,  atresia  of  the,  -10. 
contusion  of  the,  '15. 
curve  of  the,  33. 
deformities  of  the,  39. 
diseases  of  the,  30,  54. 
exploration  of  the,  35. 
external  wounds  of  the,  47. 
false  passage  in  the,  155. 
foreign  bodies  in  the,  52. 
imperforation  of  the,  40. 
injection  of  the  deep,  77. 
injuries  of  the,  45. 
internal  wounds  of  the,  48. 
irrigation  of  the,  06. 
membranous,  31. 

method  of  securing  a  catheter  in  the,  189. 
polypi  in  the,  53. 
prostatic,  144. 
size  of  the,  150. 
spongy  portion  of  the,  30. 
syphilis  of  the,  662. 
stricture  of  the,  98. 

annular,  102. 

cause  of,  105. 

cause  of  death  in,  144. 

complicated,  155. 

complicated  by  abscess,  161. 

complicated  by  enlarged  prostate,  163. 

complicated  by  fistulae,  161. 

complicated  by  pericystitis,  169. 

constitutional  disturbance  in,  144. 

continuous  dilatation  in,  163. 

diagnosis  of,  130. 

divulsion  in,  152. 

effects  of  force  in,  147. 

effect  of  the  sexual  element  in,  145. 

extravasation  of  urine  in,  138. 

infiltration  of  urine  in,  139. 

internal  urethrotomy,  152. 

intervals  between  sittings  in,  148. 

irritable,  108. 

lesion  in,  104. 

linear,  102. 

localization  of,  131. 

number  of,  103. 

organic,  102. 

resilient,  108,  155. 

seat  of,  103. 

small  caliber,  treatment  of,  153. 

size  of  insti'ument  used  in,  147. 

spasmodic,  99. 
diagnosis  of,  101. 

summary  of  treatment  of,  167. 

treatment  of,  101. 


ro4 


GFNERAL   INDEX. 


Urethni,   stricture  of   the,   time  of  oeeiir- 
rcnce  of,  after  gononlur'a  and   in- 
jury, 107. 
tortuous,  102. 
traumatic,  154. 

treatment  of  uncomplicated,  146. 
warts  in  the,  53. 
Urethral  instruments,  curve  of,  34. 

case  of  instruments,  168. 
Urethrameter,  Otis' .s,  113. 
Urcthrismus,  101. 

Urethritis,  abortive  treatment  of,  65. 
caused  by  chemical  violence,  59. 
caused  by  mechanical  violence,  59. 
causes  of,  60. 
course  of,  61. 
injections  in,  65. 
methodic  treatment  of,  6*7. 
Urethrotome,  Civialc's,  120. 
Otis's  dilating,  122. 
Maisonneuve's,  120. 
objection  to,  121. 
Urethroplasty,  166. 
Urethrotomy,  cocaine  in,  122. 

external  perineal  instruments  for,  122. 
with  guide,  126. 
without  guide,  123. 
haemorrhage  after,  120. 
internal  instruments  for,  119. 
Urine,  acidity  of  the,  322. 
alkalinity  of  the,  32 1, 
symptoms  of,  324. 
treatment  of,  325. 
condition  of,  in  nephralgia,  322. 
extravasation  of,  144. 

in  stricture  of  the  urethra,  138. 
incontinence  of,  232. 
in  adults,  233. 
nocturnal,  in  children,  232. 
treatment  of,  232. 
infiltration    of,     complicating     stricture, 
159. 
direction  in,  142. 
in  stricture  of  the  urethra,  139. 
symptoms  in,  143. 
oxalate  of  lime  in,  325. 


Urine,  retention  of,  231. 

complicating  stricture,  157. 

in  hypertrophy  of  the  prostate,  178. 

treatment  of,  231. 
test  for  residual,  in  hypertrophy  of  the 

prostate,  193. 
stone  the  logical  sequence  of  obstructed 

flow  of,  180. 
suppression  of,  320. 

diagnosis  of,  321. 

symptoms  of,  320. 

treatment  of,  321. 
"  Urnings,"  445. 

Varicocele,  450. 

diagnosis  of,  452. 

ligature  of  vessels  for,  453. 

method  of  operating,  454. 

symptoms  of,  452. 

treatment  of,  452. 
Vas  deferens,  anatomy  of,  455. 

inflammation  of,  456. 
Vegetations,  23. 

in  chancroid,  472. 

in  syphilitic  chancre,  520. 

treatment  of,  24. 
Veins,  syphilis  of  the,  649. 
Vesicle,  seminal,  anatomy  of,  456. 

atrophy  of,  457. 

hydrocele  of,  459. 

inflammation  of,  458. 
symptoms  of,  458. 
treatment  of,  459. 

tubercular  disease  of,  459. 
treatment  of,  459. 
Vitreous  humor,  syphilis  of  the,  623. 

Warts  in  the  urethra,  53. 

venereal,  23. 
Wintergreen,  oil  of,  91. 
Wounds  of  the  bladder,  226. 
treatment  of,  226. 
of  the  penis,  treatment  of,  6. 
of  the  testicle,  369. 
treatment  of,  370. 
Wrappings  of  the  penis  in  gonorrha?a,  69. 


THB    END, 


Novemher,  lf<88. 


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